1. Judy A. Gretz, RNC, MSN, DNP Emory University & Emoryhealthcare

2. During our time today we will:  Review the physiologic function and anatomy of the skin  Explore the fragility and characteristics of neonatal skin  Assess the newborn’s skin utilizing AWHONN’s EBP Guidelines  Compare sponge bathing to immersion bathing  Discuss recommended skin care practices for prevention and treatment of skin issues

3.  Barrier against infection  Protection of internal organs  Regulates insensible water loss  Secretes electrolytes and water  Provides tactile sensory input for sensations of touch, pressure, temperature, pain, and itch

5. The Epidermis is subdivided into 5 layers (from deepest to most superficial layer: ◦ Stratum basale (cellular generation layer) ◦ Stratum spinosum ◦ Stratum granulosum ◦ Stratum lucidum ◦ Stratum corneum (outermost layer & vital barrier of skin)

6.  Toxicity from topical agents ◦ Percutaneous absorption of neomycin has been reported to cause neural deafness  Increased fluid, heat loss ◦ 10-20 layers of S.C. in the adult and term newborn ◦ Preterm infants have fewer layers of S.C.  Traumatic injury  Portal of entry for infection ◦ Diminished cohesion of dermis and epidermis make infant vulnerable to blistering and trauma, i.e adhesive removal

7.  Edema  Blood flow reduced to epidermis  Risk for injury

8. Appearance Skin pH Nutritional stores Vulnerability to infection

9.  Reduce traumatic injury  Prevent dryness  Avoid exposure to toxins  Minimize exposure to unnecessary substances  Promote normal skin development

10.  Assess skin surfaces head-to-toe daily  Note risk factors in environment  Use an objective scale to assess skin condition

11.  Dryness ◦ 1 = normal, no dryness ◦ 2 = dry skin, visible scaling ◦ 3 = very dry skin, cracking/fissures  Erythema ◦ 1 = no evidence of erythema ◦ 2 = visible erythema < 50% body surface ◦ 3 = visible erythema > 50% body surface  Breakdown ◦ 1 = none ◦ 2 = small localized areas ◦ 3 = extensive

12.  Cotton surfaces, sheepskin  Water or air mattress, gel pads  Petrolatum-based emollient over groin, thigh  Transparent dressings on knees, elbows

13.  Primary cause of skin breakdown  Minimize amount of adhesive contact  Bonding agents increase risk of trauma  Mineral oil, emollients facilitate removal  Avoid toxic solvents

14.  Hydrogel electrodes, strips  Pectin barriers, hydrocolloid tapes  Soft gauze wraps  Transparent dressings  Alcohol-free skin protectants

16.  Culture, gram stain to identify colonization  Use antifungal ointment if fungus cultured  Monitor for systemic fungal infection  Consider systemic antifungal treatment

17.  Culture, gram stain to identify colonization  Use antifungal ointment if fungus cultured  Monitor for systemic fungal infection  Consider systemic antifungal treatment

18.  Flush with sterile water or ½ normal saline  Cover with petrolatum ointment  Use transparent dressings, hydrogel, hydrocolloid dressings in selected cases  Disinfectant solutions injure healing tissue

20.  Increased in premature infants <30 weeks  Select one of the following strategies: ◦ High humidity (>70% RH for 7 days) ◦ Transparent adhesive dressings ◦ Petrolatum-based emollient every 6 hrs

21.  Zinc intake 400mcg/kg/day in premature infants  Full-term infants need 100- 200mcg/kg/day, more if surgery  IV lipids 0.5g/kg/day prevents EFAD  Adequate calories, protein intake needed

22. The goals of this project were to: 1. Determine whether tub bathing lowers a newborn’s axillary temperature significantly more or less than sponge bathing. 2. Determine whether or not there is a significant difference in umbilical cord healing between newborns who are tub bathed and those who are sponge bathed from 2-24 hours of birth.

23. 3. Determine whether newborns that are tub bathed are more content during the bath than those who are sponge bathed. 4. Explore whether mothers of newborns who were tub bathed express more pleasure with the bath and are more confident regarding bathing on discharge than are mothers of newborns who are sponge bathed.

24. Goal 1: Significant? YES Goal 3: Significant? YES Goal 2: Significant? NO Goal 4: Significant? NO

25.  Vital signs, temp stable 2 – 4 hours  Antiseptic soaps not required  Universal precautions  Not necessary to remove all vernix

26.  No clinically significant heat loss when appropriate steps to preserve heat loss are taken.  Infants and mothers more content with tub bathing.  Flexible bathing time is acceptable and family choice is important.  Babies may be safely bathed at the bedside.  No difference in cord healing found.

27.  Cleanse cord during bathing  Initial application of anti-microbial agents is debatable  Routine isopropyl alcohol delays cord separation  Educate about normal cord appearance

28.  Disinfect prior to procedure  Cleanse thoroughly with water  Apply petrolatum-gauze dressings to site  No proven benefit from antimicrobial ointments

29.  Urine makes skin moist, susceptible to injury  Alkaline pH activates enzymes, bile salts in stools which cause breakdown  Identify and treat underlying cause

30. Use zinc oxide ointments Apply thick layer to prevent re-injury Use antifungal ointments for candida

31.  Improves skin condition for premature and full-term infants  Protects skin during normal development  Reduces exposure to toxic or sensitizing agents  May have long-term benefits for skin

32. I would like to thank Juanita Davis, NNP-BC for sharing slides and information for this presentation today. I also would like to thank all of the unsung heroes at the bedside, no matter their title or discipline, who each and every day support the lives of the smallest humans on earth. Thank you

33.  Anderson, G. C., Lane, A. E., & Chang, H. (1995). Axillary Temperature in Transitional Newborn Infants Before and After Tub Bath. Applied Nursing Research, 8(3), 123-128.  Bryanton, J., Walsh, D., Barrett, M., & Gaudet, D. (2004). Tub Bathing Versus Traditional Sponge Bathing for the Newborn. JOGNN, 33(6), 704- 712.  Cole, J. G., Brissette, N. J., & Lunardi, B. (1999). Tub Baths or Sponge Baths for Newborn Infants? Mother Baby Journal, 4(3), 39-43.

34.  Hardman, M.J., Moore, L., Ferguson, M. & Byrne, C. (1999) Barrier Formation in the Human Fetus is Patterned. Journal of Investigative Dermatology, p1106-1113.  Hardman, M.J. & Byrne, C. (2003). Neonatal Skin Structure & Function, Marcel Dekker Inc., USA.  Lund, C. H., Osborne, J. W., Kuller, J., Lane, A. T., Lott, J. W., & Raines, D. A. (2001). Neonatal Skin Care: Clinical Outcomes of the AWHONN/NANN Evidence-Based Clinical Practice Guideline. JOGNN, 30(1), 41-51.