ABSTRACT
BACKGROUND: The immature skin of preterm infants is uniquely vulnerable to pressure and chemical injury. We sought to qualitatively and quantitatively describe the histopathologic patterns of skin development in preterm infants. METHODS: Autopsy skin samples were examined for 48 liveborn preterm infants born at 18+ to 36 weeks, and control groups of term neonates and older infants/children. Quantitative variables included thickness of the stratum corneum, epidermis, and dermis. Qualitative features included stratum corneum, rete ridges, and hair follicles. RESULTS: Patterns of maturation were reproducible. Compact keratin appeared beginning at 21-22 weeks. Basketweave keratin appeared first around hair follicles, and then became more generalized from â¼28 weeks corrected gestational age (CGA) onward. Rete ridges began to appear at â¼30 weeks. Epidemal and dermal thickness increased with age. Infants who survived ≤7 days had thicker dermis than those who survived longer, even adjusted for CGA. CONCLUSIONS: Skin development in preterm infants has reproducible milestones. Significant structural changes occurring around 28-30 weeks may improve barrier function, with implications for use of topical compounds such as chlorhexidine. The findings also highlight challenges in evaluating pressure injuries in preterm infants, and postnatal changes in skin parameters.
Subject(s)
Infant, Premature , Skin/pathology , Case-Control Studies , Child Development , Gestational Age , Humans , Infant , Infant, Newborn , Skin/embryology , Skin/growth & developmentABSTRACT
BACKGROUND: Soft tissue injuries recognized at birth are a common occurrence and well described in the medical literature. Despite this, there has been no discussion of congenital pressure injuries. In this Clinical Challenges article, I describe 3 cases in which congenital skin injuries have occurred, all of which meet the National Pressure Ulcer Advisory Panel definition for a pressure injury and are demonstrably not the result of other etiologies. CASES: Over a 6-month period, in a 44-bed level III-IV neonatal intensive care unit, 3 patients were identified and diagnosed with congenital pressure injuries. All were born to mothers who presented with significantly diminished or a near-absence of amniotic fluid. The amniotic fluid provides essential cushioning for the developing fetus. A number of well-described conditions result from alterations in the character and volume of the amniotic fluid during gestation. Among these is a correlation between severely diminished fluid volume and congenital contractures resulting from immobility of the fetus as it is compressed against the uterine wall. Therefore, it is not unreasonable to speculate that this immobility and pressure could be the very same mechanism that created our congenital pressure injuries noted in these patients. The stages of the congenital pressure injuries noted were a stage 1, a stage 2, and also a deep tissue pressure injury. One infant succumbed to conditions related to extreme prematurity prior to healing, while the other 2 patients' injuries healed without complication or apparent long-term sequelae. CONCLUSIONS: Despite their absence in the medical literature, I assert that congenital pressure injuries occur and are clinically relevant. This lack of recognition and description risks unnecessary diagnostic procedures and inappropriate or delayed treatment.
Subject(s)
Congenital Abnormalities/diagnosis , Pressure Ulcer/diagnosis , Soft Tissue Injuries/diagnosis , Congenital Abnormalities/nursing , Female , Gestational Age , Humans , Infant, Newborn , Intensive Care Units, Neonatal/organization & administration , Male , Pressure Ulcer/physiopathology , Severity of Illness Index , Soft Tissue Injuries/physiopathology , Wound HealingABSTRACT
BACKGROUND: The skin of extremely preterm infants is underdeveloped and has poor barrier function. Skin maintenance interventions initiated in the neonatal intensive care unit (NICU) have immediate and lifelong implications when the potential for infection, allergen sensitization, and altered aesthetic outcomes are considered. In addition, the high-level medical needs of extremely preterm infants demand skin-level medical interventions that too often result in unintended skin harm. PURPOSE: We describe the use of a harm prevention, or consequence-centered, approach to skin care, which facilitates safer practice for extremely premature infants. METHOD: Neonatal and pediatric Advanced Practice Registered Nurses (APRN) came together for monthly meetings to review the evidence around best skin care practices for extremely preterm infants, with an emphasis on reduction of skin harm. Findings were focused on the population of interest and clinical implementation strategies. FINDINGS: Skin care for extremely preterm infants remains overlooked by current literature. However, clinical practice pearls were extracted and applied in a manner that promotes safer skin care practices in the NICU. IMPLICATIONS FOR PRACTICE: Gentle adhesives, such as silicone tapes and hydrogel-backed electrodes, can help to reduce medical adhesive-related skin injuries. Diaper wipes are not appropriate for use among extremely preterm infants, as many ingredients may contain potential allergens. Skin cleansers should be pH neutral to the skin and the prophylactic use of petrolatum-based emollients should be avoided. IMPLICATIONS FOR RESEARCH: Further exploration and understanding of skin care practices that examine issues of true risk versus hypothetical risk of harm.
