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Subscribe to eNeonatal ReviewApril 2009: VOLUME 6, NUMBER 8

Update on Skin Care in Premature Infants in the NICU

In this Issue...

Clinicians aim to provide skin care that supports temperature stability, minimizes fluid loss, decreases the risk for infection, reduces skin damage, and promotes comfort in preterm infants. Until recently, practice guidelines published in 2001 by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and the National Association of Neonatal Nurses (NANN), had been the standard of care for neonatal skin. In 2007, these guidelines were revised.

In this issue, we will provide an overview of the data that served as the basis for these revisions, identifying practices supported by new evidence, reviewing those practices that continue to warrant careful attention, and presenting a credentialed instrument to objectively track skin condition throughout the neonatal period.
LEARNING OBJECTIVES
At the conclusion of this activity, participants should be able to:

Compare the features of premature and mature skin
Discuss the rationale for selected interventions for the treatment of preterm skins
Identify interventions that promote healthy skin development in preterm infants in the neonatal intensive care unit (NICU)
Describe the outcomes associated with select practices for skin care in premature infants
 
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THIS ISSUE
IN THIS ISSUE
COMMENTARY from our Guest Authors
NEONATAL SKIN CONDITION SCORE
NEONATAL SKIN CARE GUIDELINES
UPDTATE ON SKIN CARE PRACTICE GUIDELINES
TOPICAL OINTMENTS FOR THE PREVENTION OF INFECTION IN PRETERM INFANTS
TRANSEPIDERMAL WATER LOSS
     
Program Directors

Edward E. Lawson, MD
Professor of Pediatrics
Johns Hopkins University
School of Medicine
Chief, Division of Neonatology
Vice Chair, Department of Pediatrics
Johns Hopkins Children's Center

Christoph U. Lehmann, MD
Associate Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins University
School of Medicine

Lawrence M. Nogee, MD
Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins University
School of Medicine

Mary Terhaar, DNSc, RN
Assistant Professor
Undergraduate Instruction
The Johns Hopkins University
School of Nursing

Anthony Bilenki, MA, RRT
Technical Director
Respiratory Care Services
Division of Anesthesiology and Critical Care Medicine
The Johns Hopkins Hospital
Baltimore, Maryland
GUEST AUTHORS OF THE MONTH
Commentary & Reviews
Mary Terhaar, DNSc, RN Mary Terhaar, DNSc, RN
Assistant Professor
Johns Hopkins University
School of Nursing
Baltimore, Maryland
     
Reviews Only
Lorraine Harbold, RN, MS Lorraine Harbold, RN, MS
Education Coordinator
NICU Staff
Neonatal Intensive Care Unit
Johns Hopkins Hospital
Baltimore, Maryland
Rebecca Gardner, RN Rebecca Gardner, RN
Clinical Nurse
Neonatal Intensive Care Unit
Johns Hopkins Hospital
Baltimore, Maryland
Nicole Tietz, RN Nicole Tietz, RN
Clinical Nurse
Neonatal Intensive Care Unit
Johns Hopkins Hospital
Baltimore, Maryland
Guest Faculty Disclosure

Mary Terhaar, DNSc, RN, has no relevant financial relationships to disclose

Lorraine Harbold, RN, MS, has no relevant financial relationships to disclose

Rebecca Gardner, RN has no relevant financial relationships to disclose

Nicole Tietz, RN, has no relevant financial relationships to disclose

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Release Date
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COMMENTARY
The 2001 practice guidelines developed by AWHONN and NANN have been the standard for neonatal skin care for nearly a decade.1 However, recent evidence from the nursing, neonatology, pediatric, dermatology, and infection control literature has contradicted some recommended practices, clarified others, and introduced new ones. To help establish skin care practices based on evidence rather than on tradition, in 2007, AWHONN and NANN revised their guidelines.2

At birth, preterm skin lacks many characteristics of the mature stratum corneum. Thin and even translucent, it is easily damaged. Preterm skin has neither the 10 to 20 layers nor the full complement of fibrils that provide mature skin with strength. Vernix caseosa partially compensates for these deficiencies during the last trimester, functioning as a moisturizer, antioxidant, and cleanser that protects the skin from infection after birth. In addition, vernix caseosa plays a key role in development of the acid mantle, healthy bacterial colonization, and wound healing.3 When the combined protection of the vernix caseosa and the intrauterine environment is lost, or when birth occurs before the skin’s protective barrier develops, immature skin is left exquisitely vulnerable to hypothermia, environmental pathogens, pain, injury, and fluid loss.

Each of these situations has the potential to complicate the management of conditions associated with prematurity. Many aspects of care—including endotracheal tubes; central venous, arterial, and peripheral lines; feeding tubes; and blood sampling — introduce significant, repeated injury and exposure to pathogens. Interventions that protect immature skin have the potential to reduce discomfort, hospital-acquired infections, complications, hospital length of stay, sequelae, and morbidity. Protecting the skin and promoting its development rank high among the goals of all NICU caregivers until preterm infants exhibit characteristics of the mature epidermis, at about 3 weeks of age.4

Current research questions several commonly accepted practices. The use of oils and emollients is associated with improved barrier function, skin integrity, and healing following skin damage; massage application is associated with enhanced behavioral integration and weight gain,5,6 and absorption of oils has been proposed as a means of augmenting nutrition.7,8 However, a risk for coagulase-negative infection has been identified,9 which contradicts broad use of oils and emollients as a best practice until both the mechanism for infection and strategies to lessen the risk have been developed and validated as effective.2,10,11 Polyethylene wraps used immediately at birth have also been the subject of ongoing research. They reduce transepidermal water loss (TEWL), thus decreasing dehydration, electrolyte imbalances, temperature instability, and caloric demands in the early neonatal period.12-16 Although the use of occlusive dressings has been shown to decrease injury resulting from securing lines and tubes, removal introduces the same risk for trauma that is associated with the removal of adhesives and tapes. The ability to observe skin while reducing friction is an added benefit.2 Humidification,17,18 which plays a key role in reducing TEWL, may also inhibit barrier function development and warrants additional study. Note that the body of research covering antiseptics, skin preps, extravasation injuries,19 and phototherapy,20 although large and growing, will not be presented in this issue.

Interventions developed and tested to promote thermoregulation, decrease fluid loss, reduce injury, and enhance skin integrity are based on strong evidence. However, interactions between interventions are not well understood. Common practices have been questioned based on findings of meta-analyses and rigorous trials with larger samples.8,9 Clinicians should refresh their knowledge of evidence-based practice, consider interactions between various treatments and products, and apply practices shown to promote skin integrity.

Table 1. Key Interventions Used on Preterm Skin Since 2000


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NEONATAL SKIN CONDITION SCORE
Lund CH, Osborne J. Validity and reliability of the Neonatal Skin Condition Score.
J Obstet Gynecol Neonatal Nurs. 2004;33(3):320-327.

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This study tested the reliability and validity of the Neonatal Skin Condition Score (NSCS) as a tool for assessing the condition of neonatal skin. NCSC is a 9-point scale that evaluates dryness, erythema, and skin breakdown. A total of 1006 infants from 27 NICUs, special care nurseries, and well baby nurseries across the United States participated. In 16 hospitals, 2 consecutive assessments for each infant were scored by a single nurse and these data were used to establish intrarater reliability. In 11 other hospitals, >1 nurse scored the infants’ skin condition, and these data were used to assess interrater reliability. Validity was established using variables from the larger data set, including birth weight; number of skin score observations for each infant; and the prevalence of infection, defined as a positive blood culture.

Total NSCS and subscale scores of dryness, erythema, and skin breakdown demonstrated intrarater (n = 475) and interrater (n = 531) reliability in the moderate range. Each of the 3 subscales (dryness, erythema, and skin breakdown) and the total score show a percent agreement between scores ranging from 68.7% to 85.4% (intrarater) and 65.9% to 89% (interrater). All kappa scores were significant (P <.001) and were in the moderate range for reliability. Discriminant validity was supported by the finding that smaller infants were 6 times more likely to have erythema and approximately twice as likely to experience severe skin breakdown. Infants with longer lengths of hospital stay were shown to have higher skin scores, and surprisingly, infected infants and those with a greater risk for infection had higher scores as well.

Subjective skin assessment in hospitalized infants does not provide an overall appraisal of skin condition, fails to evaluate specific properties, and cannot quantify the extent of skin disruption. The NSCS provide clinicians with an objective, consistent, and concise method of reporting neonatal skin condition. With subscales of dryness, erythema, and skin breakdown, as well as extent of involvement of body surfaces, the NSCS describes the overall skin condition of infants in a way that allows for consistent evaluation of change over time and promotes identification of patients who require intervention.

Subjective skin assessment in hospitalized infants does not provide an overall appraisal of skin condition, fails to evaluate specific properties, and cannot quantify the extent of skin disruption. The NSCS provide clinicians with an objective, consistent, and concise method of reporting neonatal skin condition. With subscales of dryness, erythema, and skin breakdown, as well as extent of involvement of body surfaces, the NSCS describes the overall skin condition of infants in a way that allows for consistent evaluation of change over time and promotes identification of patients who require intervention.

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NEONATAL SKIN CARE GUIDELINES
Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30(1):41-51.

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The Neonatal Skin Care Research-Based Practice Project tested the hypothesis that evidence-based clinical practice guidelines could positively affect skin integrity in the NICU, special care nursery, and well baby nursery. Guidelines included reduced frequency of bathing, increased use of emollients such as Aquaphor, decreased use of A&D ointment for diaper rash treatment (zinc and antifungal creams were preferred), use of chlorhexidine and antimicrobial ointment instead of triple dye or alcohol for umbilical cord care, and the use of humidity to prevent TEWL. Nurses in 51 participating US units were educated on the background and application of the guidelines. The skin condition of each neonate was assessed using the NSCS, which quantifies dryness, erythema, and breakdown of the baby’s skin with scores ranging from 3 (good) to 9 (bad).

In this pre-implementation/post-implementation study of the skin care guidelines, the skin of each neonate was assessed using the NSCS twice weekly for 8 weeks (or until hospital discharge, whichever came first). Over the course of 4 observations per neonate, NSCS scores improved in all infants. Neonates assessed prior to implementation of the guidelines showed improvement in their NSCS by 0.49 points over 4 visits (F=104.53, p<.0001), and those entered following implementation showed a 0.84-point improvement. Neonates who received care according to the guidelines had significantly higher NSCS scores over time (F=6.69, p<.0001). No significant difference was noted in rates of positive skin and/or blood cultures between the groups of neonates.

After implementation of the evidence-based guidelines, the skin of the neonates was scored as having less dryness, redness, and breakdown, and healed faster, than in neonates in the pre-guideline cohort. Bathing can be drying and irritating to immature skin. Findings indicate the benefits of less frequent bathing. Use of emollients was associated with improved NSCS scores without any corresponding increase in infection rate. Finally, diaper rashes were the most common type of skin breakdown. Faster healing of the buttocks using the new skin care guidelines was documented despite the decreased use of A&D ointment when caring for diaper rash. Broad implementation of these evidence-based skin care guidelines in the NICU, the special care nursery, and the well baby nursery is supported by the results of this study.


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UPDATE ON SKIN CARE PRACTICE GUIDELINES
Lund CH, Kuller J, Raines DA, Ecklund S, Archambault ME, O'Flaherty P. Neonatal Skin Care. 2nd Ed. Evidence-Based Clinical Practice Guideline. Washington, DC: Association of Women's Health, Obstetric and Neonatal Nurses; 2007.

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An AWHONN and NANN evidence-based practice team conducted a review of the literature with the intention of updating the skin care practice guidelines using contemporary research findings and the American Nurses Association framework.22 A search of MEDLINE, CINAHL, PubMed, and the Cochrane library was conducted from 2000 through 2006 using the search terms “neonatal skin care”, with the inclusion terms of skin assessment, skin nutrition, newborn bathing, immersion bathing, umbilical cord care, circumcision care, intravenous infiltration, skin irritation, diaper dermatitis, transepidermal water loss, and vernix caseosa. All studies were screened for the strength of the methods and findings, and data were used to develop this 2nd edition of Neonatal Skin Care.

The team found that although chlorhexidine gluconate–based disinfectants have been associated with decreased colonization and infections at catheter insertion sites in adult populations, no studies are available to support their safe use in neonates with central venous lines.23 Although the toxicity of povidone-iodine has been documented internationally,24-27 this substance has not been banned in the United States and Canada.28 No product containing chlorhexidine has been approved by the US Food and Drug Administration for use in the first 28 days of life, and off-label use carries risks.

Emollients effectively protect the stratum corneum and its barrier function,29 reducing dry skin and fissuring.30,31 Application must be gentle to avoid friction and associated skin damage,29 and care must be taken to prevent introducing microorganism contaminants into preparations that will be applied to fragile skin.29,32

TEWL can effectively be reduced by using occlusive polyethylene bags or tents to cover infants in the delivery suite from the shoulders down.33 This practice facilitates temperature regulation, as does the management of ambient temperature until the infant can be placed in a heated and humidified incubator. Semipermeable dressings can be used to improve skin condition, decrease TEWL, and increase weight gain, although their removal introduces risks similar to those observed with the removal of adhesives and this must be considered in their application.13-15

Handwashing and universal precautions remain vital to effective skin care, as do infrequent bathing and the use of mild, pH-neutral cleansers. Judicious application of disinfectants is the best guard against many of the complications, including skin trauma, slow healing, and hypothyroidism, that are associated with their use. Frequent care of an infant’s diaper area with soft cloths and water or commercial alcohol-free wipes can reduce the risk for skin breakdown, which is a significant problem among neonates.

Adhesive tape causes harm to neonatal skin. Pectin-based or hydrocolloid barriers cause fewer injuries and provide less opportunity for penetration of the skin barrier by opportunistic organisms. Semipermeable dressings can be used to secure lines and tubes, while allowing the skin beneath to be assessed. When adhesives are used, they should be lined with a nonadherent material to reduce contact with the skin and removed by applying pressure to the skin with a wet cotton ball while gently peeling back the tape.

Emollients and oils aid healing, but require protection from contamination with opportunistic organisms and a risk-benefit analysis, when applied. Chlorhexidine gluconate skin preparations can be used to avoid the risk for hypothyroidism associated with iodine-containing products, provided they are applied gently and minimize the exposure to alcohol.
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TOPICAL OINTMENTS FOR THE PREVENTION OF INFECTION IN PRETERM INFANTS
Conner JM, Soll RF, Edwards WH. Topical ointment for preventing infection in preterm infants. Cochrane Database Syst Rev. 2004;(1):CD001150.

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Edwards WH, Conner JM, Soll RF; for the Vermont Oxford Network. The effect of Aquaphor original emollient ointment on nosocomial sepsis rates and skin integrity in infants of birth weight 501 to 1000 grams [abstract]. Pediatr Res. 2001;49:388A.

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A Cochrane Review assessed the effects of routine prophylactic application of topical ointment on the rate of nosocomial sepsis and other complications associated with prematurity. Studies included were randomized, controlled trials comparing prophylactic application with either routine skin care or a topical ointment to manage dermatitis. Patients enrolled were <37 weeks’ gestation and treatment began within 96 hours of birth. Outcome measures included sepsis diagnosed by either a single positive blood or cerebrospinal fluid (CSF) culture. Infections in the original publications were stratified into the following groups for the purposes of reporting and analysis: (1) bacterial with known pathogen, other than coagulase-negative staphylococcus (CoNS), after 2 days of life; (2) CoNS or Staphylococcus epidermidis infection; (3) infection with any pathogenic bacteria (an aggregate measure, including CoNS and S. epidermidis); (4) any fungal infection; and (5) any nosocomial infection, including any bacterial or fungal organism. Recorded complications of prematurity included patent ductus arteriosus, bronchopulmonary dysplasia, chronic lung disease, and mortality. Overall, 4 trials satisfied the criteria for inclusion and 4 did not.

All studies included treatment with a topical ointment twice daily. Lane and Drost31 randomized 34 neonates between 29 and 36 weeks’ gestation to either the treatment or to routine skin care. Assessment of skin condition, fungal cultures, and quantitative bacterial cultures were performed twice weekly.31 Nopper and colleagues34 randomized 60 neonates at <33 weeks’ gestation. Data collection included temperature, TEWL, fluid intake, weight, skin condition, surveillance skin cultures, and blood and CSF cultures, as needed.34 Pabst and associates35 randomized 19 preterm neonates between 26 and 30 weeks’ gestation. Skin condition, fluid requirements, and skin surveillance cultures were monitored.35 In this large, multicenter trial, 1191 neonates with birth weights from 501 to 1000 grams were studied. Mortality, proven and suspected sepsis, skin condition, weight, and other complications of prematurity were measured.

All studies reported data on bacterial infections with a known pathogen other than CoNS. Meta-analysis revealed no difference in risk among infants receiving prophylactic emollient skin care compared with control infants (typical relative risk [RR], 0.90; 95% confidence interval [CI], 0.63, 1.29; typical risk difference, -0.01; 95% CI, -0.04, 0.02).

Risk for infection from CoNS was also measured, with inconsistent findings. Smaller studies by Lane and Drost31 and Pabst et al.35 documented increased, although insignificant, risk in the treatment group, whereas Nopper et al.34 reported decreased risk in the prophylactic ointment group. In the latter study, 8 infants in the control group acquired CoNS, compared with 1 in the treatment group (RR, 0.13, 95% CI, 0.02, 0.94). By contrast, the large trial had sufficient power to demonstrate increased risk (RR, 1.40; 95% CI, 1.08, 1.83). Meta-analysis including all trials documented a significantly increased risk for CoNS infection in the treatment group compared with the control group (typical RR, 1.31; 95% CI, 1.02, 1.70; typical risk difference, 0.04; 95% CI, 0.00, 0.08).

The study by Edwards et al., as well as a study by Lane and Drost,31 reported increased risk in the treatment group for any bacterial infection. Findings from the smaller studies by Nopper et al.34 and Pabst et al.35 reported reduced risk for any bacterial infection in the treatment group and did not identify risk for any bacterial infection. Meta-analysis of the 4 original trials did identify a trend toward risk for any bacterial infection in the treatment group (typical RR, 1.19; 95% CI, 0.97, 1.46; typical risk difference, 0.04; 95% CI, -0.01, 0.08).

Two of the studies, by Lane and Drost31 and Nopper et al.34 documented no fungal infections in either group. Pabst and coworkers35 reported a nonsignificant reduction in the treatment group, whereas Conner and Edwards reported a nonsignificant increase. Data on fungal infections showed no significant difference among the groups.

When all nosocomial infections (bacterial or fungal) were considered, meta-analysis showed an increased risk in the treatment group (typical RR, 1.20; 95% CI, 1.00, 1.43; typical risk difference, 0.05; 95% CI, 0.00, 0.09). The meta-analysis for all other complications of prematurity, including patent ductus arteriosus, bronchopulmonary dysplasia, chronic lung disease, and mortality, showed no significant difference between the treatment and control groups.

All studies reported improved skin condition with twice-daily application of topical emollient ointment. However, the RR for CoNS infection rose 31% and the RR for any nosocomial infection (bacterial or fungal) rose 20% in treated infants. The mechanism by which infection increased is unclear, and methods of dispensing and administering ointment varied and were inconsistently reported. Contamination might have occurred, and the ointment might have provided an environment conducive to bacterial overgrowth on fragile, immature skin. Thus, despite improved skin condition with routine application of topical emollient ointments, the increased risk for CoNS and other nosocomial infections contradicts it use in preterm infants.
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TRANSEPIDERMAL WATER LOSS
Agren J, Sjörs G, Sedin G. Ambient humidity influences the rate of skin barrier maturation in extremely preterm infants. J Pediatr. 2006;148(5):613-617.

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Transition from the aqueous intrauterine environment to the gaseous extrauterine environment presents significant challenges to the neonate. Agren and colleagues investigated the effects of relative humidity (RH) on TEWL during that transition during the first 28 days of life in a sample of 27 infants born between 23 and 27 weeks’ gestational age. The authors hypothesized that ambient humidity in the environment during the initial neonatal period might influence the rate of development of the stratum corneum and thus TEWL levels. They tested the hypothesis by randomly assigning neonates to 1 of 2 treatment groups that received care in conditions of either 50% or 75% humidity beginning on day 7 and then measuring TEWL on days 7 and 28.

Both RH in the air above the infant and TEWL, which is the rate of water evaporation from the skin (g/m2/h), were measured using the Evaporimeter Ep1 (ServoMed, Stockholm, Sweden). Nonato and Lund18 also provided a complete description of TEWL and RH.

For the first 7 days of life, all infants received care in 85% RH. TEWL measures for the infants receiving care in the 50% RH group (RH50) were 32 ±; 3 g/m2/h and measures for the infants receiving care in the 75% RH group (RH75) were 34 ±; 3 g/m2/h; no difference was documented between the groups on day 7 (P = .64; n = 22). Subsequent measurements revealed differences between the treatment groups: neonates in the higher-humidity group (RH75) experienced greater TEWL at days 14 and 28 than did those in the lower-humidity group (RH50). On day 14, TEWL measured 26 ± 4 g/m2/h among infants in the RH75 group, compared with 17 ± 2 g/m2/h among infants in the RH50 group (P = .14, n = 10). On day 28, TEWL measured 22 ± 2 among infants in the RH75 group, compared with 13 ± 1 g/m2/h among infants in the RH50 group (P <.001; n = 22). TEWL was consistently and significantly lower among infants who received care in the lower-humidity RH50 environment.

No differences were found between the groups in terms of body temperature, skin temperature, ambient temperatures, total fluid intake, weight gain, time to reach full enteral feeds, birth weight, acid-base status, mean arterial pressure, or number of transfusions administered.

The researchers concluded that the barrier function associated with stratum corneum development is more effective among infants who receive care at the lower level of RH. They reasoned that higher levels of humidity, beyond day 7, while potentially helpful in reducing TEWL may adversely affect development of the stratum corneum and the corollary barrier function, which is adaptive to the gaseous extrauterine environment.

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COMMENTARY AND REVIEW REFERENCES
1. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA.. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30(1):41-51.
2. Lund CH, Kuller J, Raines DA, Ecklund S, Archambault ME, O'Flaherty P. Neonatal Skin Care. 2nd Ed. Evidence-Based Clinical Practice Guideline. Washington, DC: Association of Women's Health, Obstetric and Neonatal Nurses; 2007.
3. Hoath SB, Pickens WL, Visscher MO. The biology of vernix caseosa. Int J Cosmet Sci. 2006;28(5):319-333.
4. Malloy MB, Perez-Woods RC. Neonatal skin care: prevention of skin breakdown. Pediatr Nurs. 991;17(1):41-48.
5. Vaivre-Douret L, Oriot D, Blossier P, Py A, Kasolter-Péré M, Zwang J. The effect of multimodal stimulation and cutaneous application of vegetable oils on neonatal development in preterm infants: a randomized controlled trial. Child Care Health Dev. 2008;35(1):96-105.
6. Darmstadt GL, Saha SK, Ahmed AS, et al. Effect of skin barrier therapy on neonatal mortality rates in preterm infants in Bangladesh: a randomized, controlled, clinical trial. Pediatrics. 2008;121(3):522-529.
7. Darmstadt GL, Saha SK, Ahmed AS, et al. Effect of topical treatment with skin barrier–enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial. Lancet. 2005;365(9464): 1039-1045.
8. Solanki K, Matnani M, Kale M, et al. Transcutaneous absorption of topically massaged oil in neonates. Indian Pediatr. 2005;42(10):998-1005.
9. Edwards WH, Conner JM, Soll RF; for the Vermont Oxford Network. The effect of Aquaphor original emollient ointment on nosocomial sepsis rates and skin integrity in infants of birth weight 501 to 1000 grams [abstract]. Pediatr Res. 2001;49:388A.
10. Kiechl-Kohlendorfer U, Berger C, Inzinger R. The effect of daily treatment with an olive oil/lanolin emollient on skin integrity in preterm infants: a randomized controlled trial. Pediatr Dermatol. 2008;25(2):174-178.
11. Stamatas GN, de Sterke J, Hauser M, von Stetten O, van der Pol A. Lipid uptake and skin occlusion following topical application of oils on adult and infant skin. J Dermatol Sci. 2008;50(2):135-142.
12. Duman N, Utkutan S, Kumral A, Köruğlu TF, Ozkan H. Polyethylene skin wrapping accelerates recovery from hypothermia in very low birthweight infants. Pediatr Int. 2006;48(1):29-32.
13. Knobel RB, Wimmer JE Jr, Holbert D. Heat loss prevention for preterm infants in the delivery room. J Perinatol. 2005;25(5):304-308.
14. Vohra S, Frent G, Campbell V, Abbott M, Whyte R. Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: a randomized trial. J Pediatr. 1999;134(5):547-551.
15. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B. Heat Loss Prevention (HeLP) in the delivery room: a randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. J Pediatr. 2004;145(6): 750-753.
16. McCall EM, Alderdice FA, Halliday HL, Jenkins JG, Vohra S. Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Syst Rev. 2005;(1):CD004210.
17. Agren J, Sjörs G, Sedin G. Ambient humidity influences the rate of skin barrier maturation in extremely preterm infants. J Pediatr. 2006;148(5):613-617.
18. Nonato LB, Lund CH. Transepidermal water loss in the intensive care nursery: Measuring techniques and research recommendations. Newborn Infant Nurs Rev. 2001;1(1):11-20.
19. Sawatzky-Dickson D, Bodnaryk K. Neonatal intravenous extravasation injuries: evaluation of a wound care protocol. Neonatal Netw. 2006;25(1): 13-19.
20. Pritchard MA, Beller M, Norton B. Skin exposure during conventional phototherapy in preterm infants: a randomized controlled trial. J Paediatr Child Health. 2004;40(5-6):270-274.
21. Conner JM, Soll RF, Edwards WH. Topical ointment for preventing infection in preterm infants. Cochrane Database Syst Rev. 2004;(1):CD001150.
22. Marek KD. Manual to develop guidelines developed for the American Nurses Association, Committee on Nursing Practice Standards and Guidelines. Washington, DC: American Nurses Publishing; 1995.
23. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002;136(11):792-801.
24. Linder N, Davidovitch N, Reichman B, et al. Topical iodine-containing antiseptics and subclinical hypothyroidism in pretermpreterm infants. J Pediatr. 1997;131(3):434-439.
25. Mitchell IM, Pollock JC, Jamieson MP, Fitzpatrick KC, Logan RW. Transcutaneous iodine absorption in infants undergoing cardiac operation. Ann Thorac Surg. 1991;52(5):1138-1140.
26. Parravicini E, Fontana C, Paterlini GL, et al. Iodine, thyroid function, and very low birth weight infants. Pediatrics. 1996;98(4 pt 1):730-734.
27. Smerdely P, Lim A, Boyages SC, et al. Topical iodine-containing antiseptics and neonatal hypothyroidism in very-low-birthweight infants. Lancet. 1989;2(8664): 661-664.
28. Gordon CM, Rowitch DH, Mitchell ML, Kohane IS. Topical iodine and neonatal hypothyroidism. Arch Pediatr Adolesc Med. 1995;149(12):1336-1339.
29. Darmstadt GL, Dinulos JG. Neonatal skin care. Pediatr Clin North Am. 2000;47(4):757-782.
30. Ghadially R, Halkier-Sorensen L, Elias PM. Effects of petrolatum on stratum corneum structure and function. Am Acad Dermatol. 1992;26(3 pt 2):387-396.
31. Lane AT, Drost SS. Effects of repeated application of emollient cream to premature neonates’ skin. Pediatrics. 1993;92(3):415-419.
32. Campbell JR, Zaccaria E, Baker CJ. Systemic candidiasis in extremely low birth weight infants receiving topical petrolatum ointment for skin care: a case-control study. Pediatrics. 2000;105(5):1041-1045.
33. Kattwinkel J. Neonatal Resuscitation: Textbook. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
34. Nopper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ, Lane AT. Topical ointment therapy benefits premature infants. J Pediatr. 1996;128(5 pt 1):660-669.
35. Pabst RC, Starr KP, Qaiyumi S, Schwalbe RS, Gewolb IH. The effect of application of aquaphor on skin condition, fluid requirements, and bacterial colonization in very low birth weight infants. J Perinatol. 1999;19(4):278-283.
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