Beyond skin deep

Research provides insights into effects of dermal care for newborns. 

Research into pressure injuries and wounds has for many years been largely focused on the older adult population. However, experts are now focusing on patients at the other end of the scale – newborns in neonatal units.

A national roadshow organised by the Australian College of Neonatal Nurses, with an unrestricted education grant from Johnson & Johnson Pacific, has been shining the light on newborns and the importance of care for their skin.

The roadshow was developed after ACNN noted the Association of Women’s Health, Obstetric and Neonatal Nurses clinical guidelines – a resource ACNN professional officer Karen New describes as extremely well-researched.

New, who is also Midwifery Clinical Academic Fellow at the University of Queensland, says that because neonatal nursing is a relatively new area in the overall health system a lot of the practices remain historically based.

“When we started asking around Australia, it was obvious that there were many different practices, and a lot of them were not keeping with best evidence that has been presented in the clinical practice guidelines,” New explains. “For many years, many people have assumed that babies and even small infants don’t suffer from pressure injuries. Obviously, with the increase in technology, the younger the preterm infant we are saving. [This means] using more devices to help save them and the pressure that is often applied from these means that we do damage their skin.

“We are now trying to build our evidence base for more of the practices that are undertaken and [skin care] is one area in which we as neonatal nurses can make a huge impact.”

Deanne August, clinical nurse at Townsville Hospital, believes the push for national standards, particularly standard 8, and the focus on hospital rating complications, are also driving the conversation about this particular topic.

August was part of the ACNN roadshow speaking on “What we know about neonatal iatrogenic skin injuries related to pressure”, which she confirms is an area that needs more research.

She is hoping to start nationwide discussion on the issue by asking people to talk about skin complication rates and what can be done to change their prevalence.

“I want to start having these conversations, not just through my unit practices but nationwide about what sorts of injuries [people] are seeing,” August says. “I am trying to speak loudly about it so people stop being scared and feeling shame about it.

“Every unit is slightly different and has slightly different practices, so it’s about saying, ‘What’s your rate, where did you get them, how did that happen?’ so we can evaluate practice that way.

“And it’s important nurses look at what injuries happen within their unit with an unbiased eye. It’s not about judgement or neglect, but it’s about why these things are happening, how regularly and what can we do locally to change them.”

A 2013 study conducted in a tertiary neonatal unit of regional Australia led by August, audited  247 patients admitted to the neonatal unit over two years.

Just over 30 per cent of the patients (77) were identified as having a skin injury, with a total of 107 injuries recorded overall.

Pressure injuries are graded in stages 1–4, with four the most severe (See “Pressure injuries in the neonatal unit”, above).

Within the study, 73 babies were graded as stage 1 or 2. Fifteen were identified as stage 3, with three patients reported as stage four. Sixteen babies were grouped into a fifth category – epithelial stripping.

The results showed that medical devices were found to be a major contributor to the development of pressure injuries, and babies who developed a single injury were at high risk of developing a second.

Researchers could not identify the portion of preventable pressure injuries, concluding the need for “further development of a risk-assessment and prevalence tool [to] provide practitioners with insight into the specific risk factors applicable for neonatal pressure injuries”.

August hopes to focus her PhD research on complications to the skin from care. Rather than simply look for the presence of complications, August plans to investigate what patients are getting them and why.

“At the moment, we have a younger group of patients coming through because our care is getting better, so it is allowing us to look at things like skin because we are doing better with our major organ systems,” she says. “I want to understand the complications and start decreasing the rate within this patient group, rather than just understanding that they are at risk because of their age.

“My ultimate aim is if we can identify factors that put the patient population at risk – whether it is identification of a gestational age or if it’s identification of nutritional content, or maybe a low birth weight. [I want to know] what put the patients at risk because not all patients get them.”

ACNN’s New says this is important work, as cases are becoming more common and can often go undetected. “We believe there are a lot of grade ones and twos that are going unrecorded,” she says.

She says skin stripping, which is different to pressure injuries, is another interesting area of focus when discussing skin care.

“A lot of tape is used to secure devices, including on the face, and the removal of the tape is important, as several layers of the epidermis are removed – this is what is meant by skin stripping.

“We are stripping and pulling away a lot of layers, particularly in the areas like the face that are exposed to elements later on in childhood. Some work overseas suggests that in children aged 4 and 5, the types of microbiomes of your skin can determine how you were delivered; so if you had a caesarean section, a normal vaginal delivery … there is a lot of work starting to come out overseas but very little here in Australia.”

New says there is also room for companies that supply tapes, emollients and moisturisers to make products more suitable for newborn skin.

Pressure injuries  in the neonatal unit

In her paper “Pressure injuries to the skin in a neonatal unit: fact or fiction”, printed in the Journal of Neonatal Nursing in 2013, Deanne August gathered definitions to classify the stages of pressure injuries in a neonatal unit. August and her team focused on the level of tissue damage, rather than ulcer shape or location above a bony prominence.

Stage 1: Persistent area of pressure related alteration to skin tone usually red (non-blanchable erythema). Epidermis remains intact but may have changes to skin temperature or tissue consistency. For darker skin, area will appear unrelenting blue, dark red, or purple. Area will continue not to blanch after more than 30 minutes after relief from pressure.

Stage 2: Partial thickness loss to underlying tissue, shallow open wound with a pink wound bed - may involve epidermis, dermis or both. May present as intact or non-intact skin in form of: typical ulcer, blister, or small crater.

Stage 3: Full thickness loss of skin tissue, that involves damage to (or maceration) underlying tissue that may include subcutaneous tissue and/or fascia. Can present as deep ulcer but may or may not show effect to surrounding tissue; present differently depending on anatomical location.

Stage 4: Full thickness tissue loss with extensive damage (may include necrosis, or damage to other structures as muscle, bone, joint, ligaments). May be associated with tunnelling (sinus tracks or undermining).

Reprinted with permission from author

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