Introduction 

Understanding the physiological and anatomical skin differences of preterm and term neonate skin is important in aiding thorough assessment and appropriate management of the skin. 

The skin contains three separate layers. The uppermost layer is the stratum corneum, provides the barrier function of the skin and has 10-20 layers in term neonates and its approximately 30% thinner than that of adults.  In preterm neonates the stratum corneum has only 2-3 layers. Directly under the stratum corneum is the basal layer of the epidermis and then the dermis which are also thinner and underdeveloped in neonates compared to adults. This deficiency and immaturity of all skin layers results in increased fluid and heat loss leading to electrolyte imbalance, reduced thermoregulation and increased infection risk.  

Please see key differences in neonate skin for further information on the structure and function of neonate skin. 

This guideline provides recommendations for the skin care of neonates (birth to 28 days of age) of all gestational ages. Additional considerations for preterm neonates and product suggestions are identified in the boxes below each section. 

Aim 

To maintain skin integrity and minimise heat loss in the neonate requiring hospitalisation. This is achieved by understanding the key differences of preterm and term neonate skin enabling appropriate assessment and management of our neonatal population using evidence based practice.     

Definition of Terms 

• Atopy - Family history of eczema, asthma or allergic rhinitis 

• Layers of the Skin -  Epidermis, Dermis and Hypodermis (subcutaneous tissue)  

• pH -  Represents the acidity or alkalinity of a solution on a logarithmic scale where 7 is neutral, < 7 is more acidic and> 7 more alkaline. 

• Stratum Corneum - The outer most layer of the epidermis  

• TEWL – Transepidermal water loss - the amount of water that passively evaporates through the skin into the air. 
  

• Vernix Caseosa - Waxy white substance on newborn skin 

Assessment 

All healthcare professionals are responsible for maintaining the skin integrity of the neonate in their care, and for the prevention, identification, treatment and documentation of pressure injury. Use of The Neonatal Skin Condition Score (NSCS) and the Glamorgan Scale Pressure Injury Risk Assessment Tool (GS)  promotes consistency in scoring and early identification of neonates at risk of skin breakdown. The RCH Nursing Guideline: Pressure injury prevention and management provides further recommendations for pressure injury. On detection of any skin breakdown the RCH Nursing Guideline: Wound assessment and management will provide further information on wound management. 

The Neonatal Skin Condition Score (NSCS) is to be documented within the first 4 hours of admission to the neonatal unit and for each nursing shift thereafter. 

Neonatal Skin Condition Score (NSCS) 

Dryness

1 = Normal, no signs of dry skin 

2 = Dry skin with visible scaling 

3 = Very dry skin with cracking and/or fissures present * 

Erythema

1 = No evidence of erythema 

2 = Visible erythema ( <50% body surface) 

3 = Visible erythema (>50% body surface)* 

Breakdown

1 = None evident 

2 = Small and/or localized areas 

3 = Extensive 

SCORING  The relevant medical team must be notified if an infant scores a single score of 3 in one area or a combined score of 6 and above. A dermatology referral may also be appropriate.

Management  

Routine Nappy Care 

The perineal environment is prone to changes in the skin barrier causing skin irritation. Increased moisture, prolonged contact with irritants, and an alkaline skin surface may contribute to skin breakdown. 

Risk factors for perineal dermatitis include: Frequent stooling, antibiotic use, malabsorption, opiate withdrawal, abnormal rectal sphincter tone. 

• Change nappies at least 4-6 hourly or more often where clinically indicated to avoid irritation to the perineal skin environment. 

• Evaluation of the perineal area is required at each nappy change to ensure early identification of perineal dermatitis and candida infections. 

• Disposable nappies are preferred. 

• Cotton balls or soft disposable towels with warm water are the preferred cleansing method 

• A pH neutral cleanser may be used if needed. Take care not to drag the skin during removal of faeces and urine. 

• The removal of barrier creams between nappy changes is not necessary, rather apply another layer. Barrier creams containing plant extracts and/or fragrance should be avoided. 

• Barrier creams should be used on all infants at risk of perineal dermatitis at every nappy change as well as at the first sign of erythema or skin breakdown. 

• If nappy rash does not improve with basic measures consider a referral to Dermatology as topical steroids may be indicated. 

• For Nappy rash see: RCH Clinical Practice Guidelines : Nappy rash (rch.org.au) 

PRETERM INFANT CONSIDERATIONS  Nappy care for the preterm infant is as above and assessed on an individual basis

Product Suggestions

Cleansing: Rediwipes®, cotton wool (non-sterile), pH neutral cleanser (examples below in bathing section)

Barrier Creams: Kenkay Zinc and Castor Oil cream ®, Conveen Critic ®, Cicaplast™, QV barrier, SudoCream ®

Eye & Oral Care 

• Routine assessment of the eyes and mouth (minimum 4-6 hourly with cares) 

• Assess for exudate, skin condition and moisture level 

Eye Care 

• If exudate appears, eyes should be wiped from the inner corner outwards with a single-use cotton ball soaked in 0.9% sodium chloride (NaCl). 

• Exudate from the eyes can be a common occurrence in the neonate however, an increase in exudate, purulent in colour may signify an infection and as such required medical review. 

• The neonate with reduced functioning of the eyelids (i.e. sedated/muscle relaxed neonate) will require routine eye care to maintain lubrication. 
  

Oral Care 

The term neonate with normal anatomy and physiology of the mouth does not require routine oral care. Routine assessment should be utilised to identify abnormalities. 
The neonate requiring regular oropharyngeal suction or with indwelling oral devices will require routine oral care to reduce injury to the lips and oral mucosa as follows:  

• Minimum 4 -6 hourly cleaning of the lips with sterile water for injection, ensuring not to pull away any skin that may be lifting prematurely. 

• Application of paraffin ointment to the lips. 

• Assessment of the tongue and oral mucosa’s moisture levels- may require a prescribed oral treatment (i.e. mucositis caused by chemotherapy). 

• Assessment of the skin condition around the mouth in particular, pressure injuries caused by equipment (i.e. ETT, Replogle tube). 

• Oral Immune Therapy with Expressed Breastmilk (EBM)is the provision of small amounts of EBM on a cotton bud (0.2mL split between each cheek) every 3 – 4 hours or in conjunction with feeds. 

• Oral Immune Therapy with EBM provides a level of immunoprotection, particularly in the extremely preterm neonate and empowers families in the care of the neonate.  
  

Bathing 

General Bathing Principles 

Implement safety principles when bathing newborns 

• Use standard precautions, including wearing gloves until after the newborns first bath. 

• Ensure bath equipment is not a source of cross contamination among newborns. 

• Implement environmental controls to create a neutral thermal environment and to minimise heat loss. 

• Bathing techniques include – immersion (tub) bathing (recommended), Swaddled (tub) bathing (recommended to reduce stress and temperature instability), Sponge bathing (least recommended). 

First Bath (applies to all newborns, additional considerations for preterm infants given below) 

• Provide the first bath once the infant has achieved cardiorespiratory and thermoregulatory stability. 

• First baths should be facilitated only when the parents are in attendance. 

• For infants born to a HIV-positive mother, the first bath should occur as soon as possible after birth. 

• Use warm tap water (temperature should be 37-37.5 °C) and a pH neutral or slightly acidic cleanser if required to assist with removal of blood and amniotic fluid. 

• Keep bath time short (approximately 5 minutes). 

• Leave vernix intact as much as possible. 

• Use appropriate rewarming measures after bathing, including skin-skin contact. 

Routine Bathing 

• Frequency of bathing and time of day should be based on individual need. Appropriate safety measures should be used. 

• Disinfect the bath before and after each use. 

• Maintain an adequately heated external environment, with an ideal room temperature of 21 - 24°C (close the doors to the room to minimise convective heat loss). 

• Water should be deep enough to allow the infants shoulders to be well covered. 

• A neutral or mildly acidic (pH 5.5 -7.0) cleanser may be used.  

• Cleansers should be free of potential irritants such as fragrance, alcohol, essential oils, plant extracts, food products, soaps and antiseptics (e.g. benzalkonium chloride). 

• Infants should be immediately covered with a towel and patted dry. 

• Ensure all skin folds are dried thoroughly (armpits, groin, neck and behind the ears). 

• As per COCOON, encourage, support and involve parents in the bathing of their infant. 

• An emollient may be applied for skin dryness (see section on emollient use). 

PRETERM INFANT CONSIDERATIONS  Bathing in preterm or ill infants with lotions or soaps can alter the pH on the skin, increasing the risk of infection. For infants more than 32 week’s gestation, pH neutral or slightly acidic cleansers may be utilised. Infants may be bathed every 2-3 days. Use warm sterile water when areas of skin breakdown are evident. If skin is dry, flaking or cracked after the bath, an emollient may be applied to the skin

Product Suggestions

Cleansing: QV Gentle Wash, Hamilton® Skin Therapy Gentle Wash, Cetaphil ® Gentle Cleanser, CeraVe® Hydrating Wash®, Dermeze® soap free wash

Emollients: As per Emollient box below

Adhesives 

A number of measures can be undertaken to ensure a reduced incidence of skin trauma with the use of adhesives in NICU 

• Choose adhesives that cause the least trauma whilst still effectively securing medical devices. 

• Consider protecting the skin with silicone-based skin protective films. 

• Tape should be backed with cotton wool where possible. 

• Avoid removing adhesives until at least 24 hours after application. 

• Remove adhesives horizontally using warm water with soft paraffin using a low and slow technique. 

• Avoid using Solvents  

• If an adhesive remover is required, consider the use of a silicone based adhesive remover (Niltac^TM). 

ETT/NPT Strapping 

• Use a silicone-based skin protective film (i.e. Comfeel® or Duoderm®). 

• Ensure tapes are cut to an appropriate size and mirror the size of the skin protective film. 

ECG Dots 

• Consider if ECG dots are truly necessary, the infant may be safely monitored using a saturation probe only. 

• Exclusive use of hydrogel electrodes. 

• Assess electrode site regularly. 

• Replace electrodes every 7 days or after bathing. 

• Remove electrodes using the ‘horizontal method’, slowly and gently with a moistened gauze square. 

Transcutaneous Monitoring (TCM) 

• Rotate between two sites every 2-4 hours. 
  

• Avoid having more than two TCM sites at any one time. 

• Decrease the TCM site temperature if redness at the site develops. 

Taping (Venous and Arterial Access) 

Current best practice exists for the taping of venous and arterial lines, however the following are general considerations. 

• Reinforcement of a CVAD dressing is not recommended as this leads to an increased risk of infection, skin breakdown and CVAD dislodgement. 

• Use Steri -StripsTM to strap around intravenous cannula.  

Intraoperative Eye Taping 

• Silicone tapes are the preferred product for taping infant eyelids intraoperatively. 

• If silicone tapes are unavailable, standard acrylate adhesive tapes are preferred (Micropore®). 

PRETERM INFANT CONSIDERATIONS  In infants <28 weeks gestation TCM temperature should be reduced to 41 degrees Celsius and rotated 2 hourly.

TegadermTM and LeukoplastTM tapes are to be avoided in infants less than 28 weeks (at minimum all brown tape is to be ‘double backed’ or dabbed with cotton wool to reduce adherence to surface area.  Silicone tape is the preferred method for reinforcement of monitoring due to its not striping nature. Eg. Parker Sil Flex TapeTM.

PRODUCT EXAMPLE

Dressings:  Comfeel®, Duoderm®, Transparent adhesive dressings (Tegaderm®), Hydrocolloids, Gel electrodes, Silicone based tapes (Siltape®, Mepitac®, 3M Kind Removal Silicone Tape®)

Disinfectants 

Skin preparation practices vary significantly with little evidence to support a consistent approach. As per the RCH CVAD policy Chlorhexidine 2% in alcohol 70% is required for all instances of insertion of vascular devices 

• If a disinfectant is required in infants less than 14 days of age and/or less than 30 weeks gestation, gently cleanse the skin with sterile water after the procedure. 

• Ensure all residual product is removed from skin and prevent any pooling.  

PRETERM INFANT CONSIDERATIONS  Skin maturation is complete after two weeks of age in the preterm population. As noted above infants under 30 weeks and/or 2 weeks of age are at an increased risk of chemical burns and should be monitored carefully during all procedures.

Umbilical Cord Care 

• Keep the cord area clean with water. Do not use alcohol wipes. 

• Cleanse with water and a pH neutral cleanser if soiled with urine or stool. 

• Fold the nappy down below the umbilicus. 

• Cord clamp may remain in situ until separation. 

• Where possible the umbilical stump should be kept exposed to air or loosely covered with clean clothing to avoid irritation and promote healing. 

• Avoid exposing the periumbilical skin to chemicals in order to prevent periumbilical burns. 

• Regular assessment is necessary to differentiate between normal umbilical cord healing and potential problems including infection. 
  

Emollients 

Emollients restore lipid levels, improve hydration, preserve natural moisturising factors and offer significant buffering capacity to normalise skin pH and maintain skin microbiome. 

• Apply an emollient daily at the first sign of dryness, fissures or flaking. 

• Maintain sterility by ordering patient specific containers or decanting products on to paper towel prior to application. Do not put hands in tubs. 

• Emollient use is not associated with negative thermal effects or burns and may be used in conjunction with phototherapy or radiant heat. 

• Emollients should contain well- tolerated preservatives. 

• Emollient use may interfere with the use of adhesives. 

• The use of oils in neonates remains a topic of contention and is currently not evidence based 

PRETERM INFANT CONSIDERATIONS  Some evidence states that prophylactic emollient use in preterm infants weighing 750 grams or less is associated with an increased risk of infection. Olive and mustard oil have been shown to impair stratum corneum development, increase TEWL and lower skin acidity. Emollient use in this population should be weighed against the risk of infection and be in consultation with the Neonatologist/Dermatology

PRODUCT EXAMPLE

Emollients: QV Cream®, Cetaphil Cream®, CeraVe® cream, Kenkay Extra Relief Cream®, La Roache Posay Lipikar Baume AP+M®, Bioderma Atoderm Crème®, Dermeze Treatment Cream®

Common Newborn Rashes 

Erythema Toxicum Neonatorum 

A common condition affecting as many as half of all full term newborn infants. Most prominent on day 2, although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs. Palms and soles are not usually affected.

Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual for an individual lesion to persist for more than a day.

Treatment: If infant is otherwise well, no treatment is required. 

Neonatal Milia

Affects 40-50% of newborn babies. Few to numerous lesions. 

Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk.

Treatment: Lesions will heal spontaneously within a few weeks of birth.

More information: Raising Children: Milia 

Miliaria (Heat Rash)

Arises from occlusion of the sweat ducts. In infants, lesions commonly appear on the neck, groins and armpits, but also on the face. 

Clinical features: 1-3mm papules (vesicular or papular).

Treatment: Remove from heated humid environment or adjust incubator temperature. Cool bathing or apply cool compresses. Ensure core body temperature remains within normal limits. Topical steroids may be used to facilitate relief while the condition resolves. 

More information: Raising Children: Heat Rash

Pityrosoprum Folliculitis 

Infantile acne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the newborns' sebaceous glands cause inflammation and folliculitis.

Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops, commonly affecting the cheeks, nose and forehead. This rash is not itchy. 

Treatment: Refer to dermatology if unresolved within weeks without treatment. May be treated with ketoconazole shampoo (i.e.  Sebizole® shampoo) diluted 1:5 with water. Apply with a cotton bud twice a day. Rinse off with water after 10 minutes. Alternatively, apply Hydrozole® cream bd to the affected areas until the rash has resolved.

Figure 5 & 6  Pityrosoprum Folliculitus (Images courtesy of of Dr David Orchard, Dermatologist RCH)

Links

RCH Nursing Guidelines

• Environmental humidity for premature neonates 
• Skin to Skin Care for the Newborn 
• Assisted thermoregulation 
• Extubation (Elective) of the Neonate on Butterfly Ward  
• Nasopharyngeal Tube NPT modified for Pierre Robin Sequence (PRS) 
• Intubation Guideline  

RCH CPGs

• Nappy Rash 

RCH Neonatal Department Guidelines

• Umbilical Arterial Catheterisation of the Newborn 
• Umbilical Venous Catheterisation of the Newborn  

RCH Policies and Procedures

• Dressing Change for Neonatal Peripherally Inserted Central Catheters