Patient safety in the prevention and care of skin lesions in newborns: integrative review

Tavares, Ingrid Vitória Ramalho; Silva, Daniela Cristina Zica; Silva, Marcella Ribeiro; Fonseca, Marina Pereira; Marcatto, Juliana de Oliveira; Manzo, Bruna Figueiredo

doi:10.1590/0034-7167-2019-0352

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Revista Brasileira de Enfermagem

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REVIEW • Rev. Bras. Enferm. 73 (suppl 4) • 2020 • https://doi.org/10.1590/0034-7167-2019-0352 copy

Patient safety in the prevention and care of skin lesions in newborns: integrative review

Seguridad del paciente en la prevención y cuidado con las lesiones de piel en recién nacidos: revisión integradora

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to describe the main evidence available in the literature on safe practices in the prevention and care of skin lesions in newborns admitted to Neonatal Intensive Care Units.

Methods:

integrative literature review in the PubMed, BDENF, LILACS, MEDLINE, SciELO and Cochrane Library databases between 2013 and 2018. We included primary articles on: lesion prevention and skin care in newborns in Portuguese, English or Spanish and excluded editorials, thesis, dissertations and duplicate articles. For the evidence level, we used the Melnyk and Fineout-Overholt classification, which classifies studies between weak to strong evidence.

Results:

a total of 10 articles with moderate to weak evidence on thermoregulation, bathing, lesion prevention, use of patches and skin antisepsis.

Final considerations:

there was a shortage of publications with high evidence, and it is necessary to invest in research that seeks to support safer skin care practices.

Descriptors:
Newborn; Skin; Nursing; Nursing Care; Patient Safety

Authors/Article Title	Year/ Country	Design/sample	Interventions	Main Results	Recommendations/ Conclusions
Christine A.S, Theresa A.M. Under pressure: preventingpressure ulcers in critically illinfants⁽¹¹11 Schindler CA, Mikhailov TA, Cashin SE, Malin S, Christensen M, Winters JM. Under pressure: Preventing pressure ulcers in critically ill infants. J Spec Pediatr Nurs. 2013; 18(4):329-41. doi: 10.1111/jspn.12043. https://doi.org/10.1111/jspn.12043.... ⁾	2013 USA	Quasi Experimental/(n=399 children from 0 to 3 months)	To determine if Bundle on prevention of ulcers by pressure was associated with a significant reduction in ulcers by pressure on children in Neonatal and Pediatric Intensive Care Units. Bundle Components included: to ensure that patients were kept in correct surface support to decrease the pressure of tissue interface; frequent turning; management of incontinence; proper nutrition and education.	The use of the Bundle was associated with a significant decrease in the incidence of ulcers by pressure from 18.8 to 6.8%.	Pressure ulcers can be Prevented in the most vulnerable patients with the implementation consistent of interventions based in scientific evidence and support systems to assist the nurses by changing practice.
Tina L, Carol B. Randomized, Controlled Trial Evaluating a Baby Wash Product on Skin Barrier Function in Healthy, Term Neonates⁽¹²12 Tina L, Bedwell C, Roberts SA, Hart A, Turner MA, Carter LA, Cork M. Randomized, controlled trial evaluating a baby wash product on skin barrier function in healthy, term neonates. J Obstet Gynecol Neonatal Nurs. 2013; 42(2):203-14. doi: 10.1111/1552-6909.12015 https://doi.org/10.1111/1552-6909.12015... ⁾	2013 England	Randomized Controlled Study (n=242 newborn <1-month-old)	To examine if a product formulated for the bath of newborn has different outcomes compared to bath with water alone.	Significant differences were not found in pH measurements and transepidermal water loss between the two groups.	The authors suggest the use of neutral product or other technically equivalente cleaners.
Visscher M.O, Taylor T. Neonatal intensive care practices and the influence on skin condition⁽¹³13 Visscher MO, Taylor T, Narendran V. Neonatal intensive care practices and the influence on skin condition. J Eur Acad Dermatol Venereol. 2013; 27(4):486-93. doi: 10.1111/j.1468-3083.2012.04470.x https://doi.org/10.1111/j.1468-3083.2012... ⁾	2013 USA	Cohort Retrospective (n=130, being 97 preterm infants and 33 newborn at term)	To examine the effects of prematurity and gestation age (time to adaptation) in maturation and integrity of stratum corneum in newborns Neonatal Intensive Care Units.	The shorter gestational age, time of contact with the feces, the use of formulas and parenteral nutrition influence the appearance of lesion.	The low exposure to feces and the longest time before the first contact with feces seem to be protective against skin damage.
Simone V.S, Roberta C. Prevention of newborn skin lesions: knowledge of the nursing team ⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾	2015 Brazil	Convergent care Care Research (n=14 nursing professionals)	To determine the knowledge of the nursing teams about practice and prevention of skin lesions in newborns hospitalized in neonatal units.	The results point that professionals have knowledge of particularities of the newborn's skin and recognize the need for care on thermal regulation, transepidermal water loss, hygiene, hydration and handling in addition to care with invasive procedures, prevention of pressure lesions, and care with venous and arterial punctures and the use of antiseptics.	Despite the knowledge of staff in regarding skin care, it is necessary to ensure training and team discussion about the theme seeking to ensure the standardization and improvement of care provided.
Simone V.S, Roberta C. Treatment of skin lesions in newborn children: meeting the needs of nursing staff⁽¹1 Santos SV, Costa R. Treatment of skin lesions in newborn children: meeting the needs of nursing staff. Rev Esc Enferm USP. 2014; 48(6):985-92. doi: 10.1590/S0080-623420140000700004 https://doi.org/10.1590/S0080-6234201400... ⁾	2014 Brazil	Convergent care Care Research (n=14 nursing professionals)	To know the Care needed for the treatment of skin lesions in NBs admitted to a Neonatal unit.	The results showed that team presents difficulties to treat skin lesions in RN, seen that the findings revealed the lack of standardization of the conducts, which makes it difficult to take a decision and to keep assistance to RN.	It is urgent the need the team know about the lesion treatment, in order to provide safer care to RN and favor the autonomy of nursing professional in care achievement
Young DL, Chakravarthy D, Drower E, Reyna R. Skin Care Product Evaluation in a Group of Critically Ill, Premature Neonates⁽¹⁵15 Young DL, Chakravarthy D, Drover E, Reyna R. Skin care product evaluation in a group of critically ill, premature neonates: a descriptive study. J Wound Ostomy Continence Nurs. 2014; 41(6):519-27. doi: 10.1097/WON.0000000000000083 https://doi.org/10.1097/WON.000000000000... ⁾	2014 USA	Descriptive Study (n=29 PTN)	To describe the impact of a specific product containing a gel or foam base cleaner, two moisturizers, including one with silicone and one protective cream with zinc oxide on the PTN skin.	Statistics differences were not found in pain scores (p = 0.132), perineal erythema (p = 0.059) or skin condition (p = 0.603) of the RN between the beginning and end of study.	The use of the new hygiene product has not improved significantly total skin condition, erythema and pain in newborns of the study.
Michelle T.M, Sarah N.D. Skin lesions of newborns in a neonatal unit: descriptive study⁽¹⁶16 Migoto TM, Souza SNDH, Rossetto EG. Skin lesions of newborns in a neonatal unit: observational study. Online Braz J Nurs. 2013; 12(2):377-92. doi: 10.5935/1676-4285.20134042 https://doi.org/10.5935/1676-4285.201340... ⁾	2013 Brazil	Longitudinal, observational study (n=40 NB)	To describe the types of treatments according to lesions found in newborns.	A total of 195 skin lesions were identified, with average of five lesions in each RN. The dermatitis caused by diaper was the most incident lesion, and lesion caused by adhesive labels and nasal lesions were less expressive. There was significant statistics for the antifungal use in dermatitis caused by diapers and the use of Essentials Fatty acids in treatment of lesions by adhesives labels and nasal lesions.	The findings point to the need for preventive lesion treatment, which can improve the quality of life and consequently growth for newborns.
Ulrike B.P, Tina L. Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care⁽¹⁷17 Blume‐Peytavi U, Lavender T, Jenerowicz D, Ryumina I, Stalder JF, Torrelo A. et-al. Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care. Pediatr Dermatol. 2016; 33(3):311-21. doi: 10.1111/pde.12819 https://doi.org/10.1111/pde.12819... ⁾	2016 Germany	Descriptive Study	To provide information relating to care practices with newborns, such as the bath and cleaning, the exchange of diapers and hygiene of this area and the use of emollients and other formulated products.	To use only water or liquid soaps properly produced. These can be used during the bath, without harming the process of skin maturation.	It is expected that health professionals use these recommendations based on evidence to guide parents to respect of cleaning practices, bath, hydration and care with the diaper area.
				The diaper area should be kept clean and dry and can be gently cleaned with cotton squares/balls and water or using tissues properly developed.
				Oils appropriately formulated for babies can be applied to skin physiological dryness (transitional) and in small quantities for the bath.
Lori D.M, Jodi H.B, Sandra L.S. Hydrocolloid to prevent breakdown of nares in preterm infants⁽¹⁸18 Morris LD, Behr JH, Smith SL. Hydrocolloid to Prevent Breakdown of Nares in Preterm Infants. MCN Am J Matern Child Nurs. 2015; 40(1):39-43. doi: 10.1097/NMC.0000000000000099 https://doi.org/10.1097/NMC.000000000000... ⁾	2015 USA	Cohort Retrospective (n = 53 NB of very low weight)	To determine if a hydrocolloid double barrier dressing prevents the trauma of the nostrils and columella in very low weight NB (<1500g) receivingheated oxygen and humidified via high flow nasal cannula.	There was no significant differences conditions of nostril skin between groups or throughout the time.	No statistics difference between groups may have been caused by the greater surveillance of NICU nurses facing the risk of trauma to the skin. In addition, the replacement of nasal CPAP by heated oxygen and humidified via high flow nasal cannula, which makes less pressure on the tissues of the nostrils, is becoming more common.
Amer M, Diab N, Soliman M, Amer A. Neonatal skin care: what should we do? A four-week follow-up randomized controlled trial at Zagazig University Hospitals⁽¹⁹19 Amer M, Diab N, Soliman M, Amer A. Neonatal skin care: what should we do? A four‐week follow‐up randomized controlled trial at Zagazig University Hospitals. Int J Dermatol. 2017;56 (11):1198-203. doi: 10.1111/ijd.13735 https://doi.org/10.1111/ijd.13735... ⁾	2017 Egypt	Randomized Controlled Study (n=70 newborns)	To evaluate effectiveness of skin care in the neonatal period, to promote normal skin development and protection of skin function great, to avoid the many different neonatal cutaneous disturbances that cause infections of skin. That is achieved by optimization of integrity of epidermal barrier, including the bath and the use of softeners, preventing and managing infections and lesions of the skin, and minimizing the transepidermal water loss (TEWL) and heat or absorption percutaneous toxins.	There were significant differences between the group of newborns that received the conventional skin care without standardization of products, and the group that received care with cleaning products designed for the baby's skin, that is, with neutral ph and gentle. The last one had less allergic dermatitis.	It is recommended the use of especially developed products for cleaning baby's skin with neutral pH and very gentle to prevent irritant dermatitis and allergic dermatitis.

Recommendations for safe skin care of hospitalized newborn	Level
1 - General care in the prevention of skin lesions
Use of superabsorbent disposable diapers with changes every three to four hours or when soiling occurs⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
The diaper area should be gently wiped with cotton balls or soft wipers and water⁽¹⁷17 Blume‐Peytavi U, Lavender T, Jenerowicz D, Ryumina I, Stalder JF, Torrelo A. et-al. Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care. Pediatr Dermatol. 2016; 33(3):311-21. doi: 10.1111/pde.12819 https://doi.org/10.1111/pde.12819... ⁾.	5
Essential fatty acid (EFA) emollients should be applied immediately after bathing, and fragrant products should be avoided because of the risk of sensitization and irritation⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
Emollients should be applied in a thin layer to avoid occlusive effects and entrapment of emollients between the skin⁽¹⁷17 Blume‐Peytavi U, Lavender T, Jenerowicz D, Ryumina I, Stalder JF, Torrelo A. et-al. Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care. Pediatr Dermatol. 2016; 33(3):311-21. doi: 10.1111/pde.12819 https://doi.org/10.1111/pde.12819... ⁾.	5
Use of zinc oxide as ointment or cream for three to five days in cases of perianal hyperemia⁽¹⁹19 Amer M, Diab N, Soliman M, Amer A. Neonatal skin care: what should we do? A four‐week follow‐up randomized controlled trial at Zagazig University Hospitals. Int J Dermatol. 2017;56 (11):1198-203. doi: 10.1111/ijd.13735 https://doi.org/10.1111/ijd.13735... ⁾.	1
2 - Bath and body care products
The premature baby should be washed only with water, two to three times a week, discouraging daily bathing and the use of soaps⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
3 - Thermoregulation and moisturizing skin
Use of a cotton cap on the newborn's head, reducing heat loss through the cephalic region⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
Use of occlusive skin cover with polyurethane film to reduce evaporative heat loss⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
Use of cribs and incubators, being the humidified incubators more suitable for newborns weighing less than 1000g and gestational age below 30 weeks⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
4 - Use of dressings and adhesives
Use of silicone skin dressing, polyurethane film, hydrocolloid or hydrogel dressing⁽¹1 Santos SV, Costa R. Treatment of skin lesions in newborn children: meeting the needs of nursing staff. Rev Esc Enferm USP. 2014; 48(6):985-92. doi: 10.1590/S0080-623420140000700004 https://doi.org/10.1590/S0080-6234201400... ⁾.	6
Removal of adhesives should be done carefully, using gauze moistened with saline or mineral oil⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
5 - Skin antisepsis before invasive procedures
The most commonly used products for skin antisepsis are isopropyl alcohol, aqueous or alcoholic chlorhexidine gluconate (CHG)⁽¹⁴14 Santos SV, Costa R. Prevention of newborn skin lesions: knowledge of the nursing team. Texto Contexto Enferm. 2015; 24(3):731-9. doi: 10.1590/0104-07072015011230014 https://doi.org/10.1590/0104-07072015011... ⁾.	6
Small amounts of 0.5% alcohol chlorhexidine are recommended. Aqueous chlorhexidine prevents chemical burns and is recommended for use in extreme preterm infants⁽¹1 Santos SV, Costa R. Treatment of skin lesions in newborn children: meeting the needs of nursing staff. Rev Esc Enferm USP. 2014; 48(6):985-92. doi: 10.1590/S0080-623420140000700004 https://doi.org/10.1590/S0080-6234201400... ⁾.	6

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[1] Corresponding author: Bruna Figueiredo Manzo. E-mail: brunaamancio@yahoo.com.br