DOI: 10.1111/pde.

13725

Pediatric
Dermatology

Evidence‐based skin care in preterm infants

Ayan Kusari MA1,2 | Allison M. Han BA1,2 | Cesar A. Virgen MD, PhD3 |
Catalina Matiz MD4 | Maynard Rasmussen MD6 | Sheila F. Friedlander MD1,2 |
Dawn Z. Eichenfield MD, PhD5

1
Division of Pediatric and Adolescent
Dermatology, Rady Children's Hospital, San Abstract
Diego, California Most guidelines on neonatal skin care emphasize issues pertaining to healthy, term
2
Departments of Dermatology and
infants. Few address the complex task of skin barrier maintenance in preterm, very
Pediatrics, University of California, San
Diego School of Medicine, San Diego, preterm, and extremely preterm infants. Here, we provide an evidence‐based review
California
of the literature on skin care of preterm neonates. Interestingly, the stratum cor-
3
Department of Dermatology, University of
California, Irvine School of Medicine, San neum does not fully develop until late in the third trimester, and as such, the barrier
Diego, California function of preterm skin is significantly compromised. Numerous interventions are
4
Department of Dermatology, Southern
available to augment the weak skin barrier of neonates. Plastic wraps reduce the
California Permanente Medical Group, San
Diego, California incidence of hypothermia while semipermeable and transparent adhesive dressings
5
Department of Dermatology, University of improve skin quality and decrease the incidence of electrolyte abnormalities. Tub
California, San Diego School of Medicine,
San Diego, California
bathing causes less body temperature variability than sponge bathing and can be
6
Sharp Healthcare System, San Diego, performed as infrequently as once every four days without increasing bacterial colo-
California nization of the skin. Topical emollients, particularly sunflower seed oil, appear to
Correspondence reduce the incidence of skin infections in premature neonates—but only in develop-
Dawn Z. Eichenfield, MD, PhD, Department ing countries. In developed countries, studies indicate that topical petrolatum oint-
of Dermatology, University of California, San
Diego School of Medicine, San Diego, CA. ment increases the risk of candidemia and coagulase‐negative Staphylococcus
Email: [email protected] infection in the preterm population, perhaps by creating a milieu similar to occlusive
Funding information dressings. For preterm infants with catheters, povidone‐iodine and chlorhexidine are
National Institutes of Health comparably effective at preventing catheter colonization. Further studies are
necessary to examine the safety and efficacy of various skin care interventions in
premature infants with an emphasis placed on subclassifying the patient population.
In the interim, it may be beneficial to develop guidelines based on the current body
of evidence.

KEYWORDS
barrier, bath, catheter, cord care, dressings, emollients, evidence-based, infant, neonatal,
neonate, newborn, premature, preterm, skin, skin care, skin care, systematic review,
thermoregulation, vasomotor

1 | INTRODUCTION currently exist in preterm neonates. In preterm neonates (those born

at gestational age < 37 weeks), the skin barrier is significantly com-
The skin functions as the first barrier of defense against pathogens, promised. Skin quality varies dramatically by gestational age at birth;
maintaining homeostasis by minimizing unnecessary fluid losses and the skin of those 23 weeks and under may be translucent, gelati-
electrolyte imbalances. To date, guidelines for neonatal skin care in nous, and extremely fragile, whereas the skin of neonates born at an
healthy term infants have been published,1 but no guidelines older gestational age may be more resilient. An intervention that is

16 | © 2018 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/pde Pediatric Dermatology. 2019;36:16–23.

KUSARI ET AL. Pediatric | 17
Dermatology

BOX 1 Summary of findings on skincare in preterm neonates

In the NICU, the following interventions have been shown to be beneficial in preterm neonates:
• Short-term application of nonadhesive polyethylene wraps within 10 minutes of birth
• Placement in humidified incubators
• Longer-term application of semipermeable, transparent dressings
• Air-drying the stump of the umbilical cord rather than cleansing with antiseptics
• Consensus is lacking on the preferred antiseptic in NICUs, although there is some evidence to support dilute chlorhexidine (0.2%) or
povidone-iodine for the very and extremely preterm
After discharge from the NICU, the following interventions have been shown to be beneficial in preterm neonates:
• Tub bathing rather than sponge bathing
• Bathing every 4th day

The following findings have been associated with use of emollients on preterm neonates:
• In developed countries, preterm neonates treated with topical petrolatum exhibit increased rates of candidemia and coagulase-
negative Staphylococcus infection
• In developing countries, preterm neonates treated with emollients exhibit reduced nosocomial infections and improved skin condition

appropriate for a neonate born at 35 weeks of gestational age may an evidence quality grade of I, II, or III based on their study design1
be insufficient for a neonate born at 30 weeks. Comorbid conditions, were included in the study. Articles assigned an evidence quality
such as congenital infections and genetic diseases, can also affect grade of I were well‐conducted randomized controlled trials (RCTs)
skin integrity and determine which therapeutic measures are appro- or meta‐analyses with sufficiently large sample sizes to minimize the
priate. Therefore, care of any particular neonate's skin must be risk of false‐positive or false‐negative results. Articles assigned an
customized and targeted to the infant's needs. evidence level grade of II were well‐designed RCTs with smaller sam-
There are a number of unifying features that distinguish preterm ple sizes. Finally, articles assigned an evidence level grade of III were
skin from term skin. Preterm skin is thinner, making preterm neo- case series, case‐control, cross‐sectional, or cohort studies—observa-
nates more susceptible to skin infections and caustic agents. The tional studies without randomization. A total of 68 articles were
vernix caseosa is typically thicker in preterm neonates (though thin- used to synthesize this review, and these are summarized by topic in
ner in extremely preterm neonates).2 Accordingly, there are a num- Tables S1-S13 (Appendix).
ber of general principles that can guide skin care for most preterm
neonates. In this study, we perform a review of the current available
3 | RESULTS
literature on preterm skin and skin care and summarize the existing
literature on skin development and skin assessment in preterm
3.1 | Skin development
neonates (Box 1). We also investigate interventions to improve skin
barrier function in preterm neonates of all gestational ages, The stratum corneum starts to develop at 15 weeks of gestational
particularly bathing, emollients, massage, occlusive skin wrapping, age (GA), but this process is not complete until approximately
semipermeable dressings, and transparent adhesive dressings, as well 34 weeks GA (Table S1). Neonates born before 30 weeks have a
as optimal cord care and intraarterial or intra‐arterial catheter care. thin epidermis with fewer cell layers and impaired epidermal bar-
rier function.3 In contrast, term infants have a thicker stratum cor-
neum than adults, since the epidermis is not adequately sloughed
2 | METHODS in utero, as it is in postnatal life. Most preterm infants develop
skin resembling that of a term infant by about 2 weeks of age,
A literature search of all published articles on PubMed through though this process can take as long as 4 weeks or even longer
March 12, 2018 was conducted, using the following Boolean search in ultra‐low birthweight infants, who are typically very or extre-
terms: skin, skin care, emollients, baby, infant, neonate, neonatal, mely preterm.4 The gender of the neonate and antenatal adminis-
newborn, preterm, premature, emollients, soap, cleanser, detergent, tration of steroids do not appear to affect epidermal development.
cleansing, bathing, washing, oil, shampoo, moisture, cream, lotion, Interestingly, the skin's acid mantle appears to vary little between
ointment, emollient, wash cloth, towel, sponge, wipe, and semi- term and preterm neonates. In both, a neutral to mildly acidic skin
permeable. Of the articles obtained through this search, only articles pH is seen at birth (Table S2). The pH decreases sharply in the
written in English and pertaining to human infants were considered. first week of life and continues to decrease gradually over the fol-
No animal or basic science research was included. Articles assigned lowing 3 weeks (Table 1).
18 | Pediatric KUSARI ET AL.

Dermatology
Skin pH, skin hydration, and erythema are improved when the warmer air can carry more water. Therefore, if a warmer room has
vernix caseosa, a cheesy protein‐ and lipid‐containing material syn- the same relative humidity as a colder room, the warmer room will
thesized in utero by fetal sebaceous glands, is retained. Synthesis of have a higher water vapor pressure.
vernix caseosa is thought to begin around 28 weeks of gestational Preterm neonates nursed in humidified isolettes, such as hybrid
age, as it is typically absent in neonates born at less than this gesta- humidified incubators, have lower fluid requirements, improved elec-
tional age, and in neonates weighing < 1000 g.5 In a sample of 430 trolyte balance, higher urine output, and increased growth velocity9
infants, those born at 33‐37 weeks GA were found to have a mean compared to preterm neonates cared for in radiant warmers
70% body surface area covered with vernix at birth, compared to (Table S6). The relative humidity that should be used in different
40% BSA in full‐term infants (37.1‐40.9 weeks) and 15% BSA in groups of neonates is not yet known. One study involving 22 ex-
those born post‐term (> 41 weeks).6 tremely preterm neonates (23‐27 weeks GA) found that the 11
neonates assigned to 75% relative humidity exhibited delayed skin
maturation (including slower decline in TEWL) than those assigned
3.2 | Skin barrier and heat dissipation in preterm
to 50% relative humidity.10 Clearly, there are contrasting forces at
neonates
play since increased humidity reduces fluid and electrolyte loss, as
Two means of assessing skin barrier function in preterm neonates well as the need for intravenous fluids, but unfortunately delays skin
are transepidermal water loss (TEWL) and transcutaneous drug maturation.
absorption. TEWL can be measured using two major categories of Preterm epidermis is thin and highly permeable to drugs. Multiple
devices—open or closed chamber devices. Though a detailed discus- studies have shown increased transcutaneous absorption of drugs in
sion of these devices is beyond the scope of this review, in either very preterm and extremely preterm neonates. For these neonates,
case, the chamber measures the amount of moisture that passes transcutaneous drug absorption falls steadily after birth.11 Care of
from within the body through the skin. TEWL is measured in grams preterm infants often involves placement of cutaneous monitors and
per meter squared per hour, and a higher value generally reflects a adhesive tapes, and these appliances can further disrupt the skin
less competent skin barrier. Large, insensible TEWL occurs in very barrier and increase transcutaneous drug absorption (Table S4). Most
preterm and extremely preterm neonates. Infants with a birthweight preterm infants exhibit little transcutaneous drug absorption after
below 1250 g are particularly susceptible, and an inverse exponential 2 weeks of life, their skin having largely matured to resemble their
relationship exists between gestational age and TEWL. A neonate term counterparts.
born at 25 weeks is likely to have TEWL 15 times that of a neonate Cutaneous thermoregulation is a particular challenge for preterm
born at full term.7 infants. Term infants, such as adults, dissipate heat in part by vasodi-
Generally, more preterm neonates have higher TEWL at birth lating cutaneous vessels and perspiring. The ability of preterm
and require longer periods of time to normalize TEWL (Table S3). infants to alter cutaneous blood flow in response to external thermal
Neonates born at 34‐41 weeks GA experience high TEWL during stimulation is greatly impaired. Likewise, infants born prior to
the first four hours after birth, which normalizes rapidly thereafter. 36 weeks of gestation are unable to sweat at birth, though interest-
In contrast, neonates born at 30‐33 weeks GA take longer (about ingly, they develop the ability to sweat by 13 days following birth.12
1 week) to normalize their TEWL. Neonates born at < 30 weeks GA
exhibit high TEWL even 2 weeks after birth.8
3.3 | Interventions to augment the premature skin
Transepidermal water loss occurs primarily through diffusion and
barrier
evaporation. The rate of diffusion depends largely on stratum cor-
neum function, whereas the rate of evaporation varies based on the
3.3.1 | Bathing
humidity of the neonate's environment. The relative humidity is the
ratio of the actual water vapor content in the air to the water vapor Eight studies have examined the issues surrounding bathing preterm
capacity of the air. Water vapor capacity varies by temperature— neonates and are primarily concerned with three topics: (a) fre-
quency of bathing (every other day vs every fourth day); (b) method
of bathing (tub bathing vs sponge bathing); and (c) effect of various
T A B L E 1 Classification of preterm neonates by gestational age bathing modalities on the cutaneous microbiome (Table S7).
and birthweight In preterm infants, bathing every 4 days does not appear to neg-
Gestational age Birthweight atively impact skin flora compared to bathing every other day. Colo-

Extremely preterm Extremely low nization by pathogenic bacterial strains, size of the total bacterial
population, and incidence of skin infection do not vary between pre-
< 28 wk < 1000 g
term infants bathed every 2 days and preterm infants bathed every
Very preterm Very low
4 days in all studies, which has been most recently demonstrated in
< 32 wk < 1500 g
a 2018 randomized interventional trial.13 Interestingly, the 2018
Preterm Low
study also demonstrates that bathing every 4 days decreases the risk
32‐37 wk < 2500 g
of temperature instability in preterm neonates.
KUSARI ET AL. Pediatric | 19
Dermatology
Tub bathing is less likely than sponge bathing to cause body applied to their skin require less fluids, showing improved urine
temperature variability in preterm neonates. In sponge bathing, wet output and electrolyte balance.25 Another study comparing olive
skin is more exposed to ambient air, which is typically colder than oil cream (70% lanolin, 30% olive oil), Bepanthen® Antiseptic
body temperature. Physiological and behavioral parameters in pre- Cream (Bayer AG, Leverkusen, Germany), and no emollient, also
term infants are often disrupted during sponge bathing.14 In contrast, shows less incidence of dermatitis and better skin conditions in
tub bathing results in less variability in body temperature and war- neonates treated with olive oil cream.26 A more recent 2018 study
mer temperatures after bathing.15 also recapitulates coconut oil's favorable effect on the neonatal
The use of different emollient cleansers or “baby wipes” has also skin condition score (NSCS) in preterm infants.27 Several other
been studied in preterm neonates. Some studies have demonstrated studies also demonstrate significantly improved skin conditions and
desirable results, though some wipes may cause allergic contact der- less dermatitis, with surprisingly little to no change in fungal and
matitis. In one study, commercial baby wipes, impregnated with glyc- bacterial colonization.28,29
erin and citric acid, produced a significantly lower skin pH than In contrast, multiple studies show an increased risk of sepsis
water‐moistened cloth wipes. In preterm neonates, this lower skin with the application of petrolatum ointment to preterm neonates.
pH may facilitate acid mantle development, infection control, and In one study, following the adoption of a new skin care protocol
barrier repair.16 involving regular application of petrolatum‐based ointments for
extremely low birthweight (ELBW) neonates, researchers in Texas
started to observe a substantial increase in the incidence of sys-
3.3.2 | Emollients and massage
temic candidiasis in these neonates from 0.5 per 1000 person‐days
Numerous studies have examined the efficacy of emollient (particu- to 1.7 per 1000 person‐days, a greater than threefold increase.18 A
larly oil) massage in improving skin condition and preventing nosoco- similar randomized controlled trial in Riyadh, Saudi Arabia, utilizing
mial infections (Tables S8-S9). In developing countries where oil daily application of petroleum jelly ointment in 74 neonates born
massage of infants and children is traditional, there appears to be a at GA < 32 weeks (a heterogeneous group including both VLBW
clear benefit to massage with some oils.17 In developed countries, and ELBW infants) also shows more episodes of culture‐proven
research has emphasized petrolatum‐based creams and ointments, nosocomial (19 episodes vs 16 episodes, a 30% increase).19 The
whose benefits are tempered by the increased risk of serious infec- largest study examining the effect of topical petrolatum‐based oint-
tions with some products.18-20 ment on ELBW infants, involving over 100 NICUs from the Ver-
Sunflower seed oil has been shown to reduce the incidence of mont Oxford Network (1191 ELBW neonates ≤ 27 weeks GA in a
nosocomial infections and improve skin condition in studies con- randomized clinical trial), shows a statistically significant increase in
ducted in Bangladesh and other developing countries.17 Aquaphor® coagulase‐negative staphylococcus (CoNS) infection with petrolatum
Healing Ointment (Beiersdorf AG, Hamburg, Germany) appears to use, but does not show significant differences in death or nosoco-
have a similarly beneficial effect when used in developing countries, mial bacterial sepsis.20 This increase in CoNS infection in the Ver-
though it may be less readily available in rural settings and has been mont Oxford Network study appears to be the driving force in a
shown to be not as effective as sunflower seed oil at reducing noso- Cochrane Database meta‐analysis, which concludes that topical
comial infections in two Bangladeshi studies.21 Interestingly, a more emollients are associated with increased CoNS infection in preterm
recent study from Germany shows that sunflower seed oil massage neonates.30
22
can impair skin barrier maturation and increase TEWL. Topical In conclusion, the benefit of topical emollient application in pre-
coconut oil application has also shown a benefit in maintaining skin term neonates has not been demonstrated as consistently in studies
integrity and reducing the risk of bloodstream infections in a conducted in developed countries as they appear to have been
Pakistani study.23 However, not all oils should be used for mainte- demonstrated in developing countries. Furthermore, data on topical
nance of skin barrier integrity. In Nepal and parts of northeastern emollient use and infection are mostly limited to extremely preterm
India, mustard oil massage is traditionally believed to keep neonates neonates. At this time, it is unclear whether preterm neonates who
warm, but a 2017 interventional controlled study showed that are older (> 27 weeks) are at similar risk. The risk of Candida infec-
preterm neonates receiving vigorous mustard seed oil massage have tion resulting from topical emollient use, though widely known in
decreased skin barrier integrity and increased skin irritation, as well the pediatric community, is based on a single case‐control study per-
as duct blockage, when compared to neonates who did not receive formed after a single hospital implemented a new protocol for petro-
24
this intervention. latum use in extremely low birthweight neonates. Similarly, increased
In developed countries, seven studies and one meta‐analysis risk of CoNS infection with topical emollient use has only been
have yielded mixed results (Table S9). Multiple studies demonstrate observed in extremely preterm neonates. Despite the paucity of evi-
that neonates treated with emollients consistently show improved dence, institutional guidelines in Western countries often prohibit or
skin conditions; however, a few studies do demonstrate an strongly discourage the use of petrolatum‐based topical emollients
increased risk of serious infections following application of petrola- since they can promote a milieu similar to occlusive dressings,18
16-18
tum‐based ointments and other emollients. In one small cohort despite the known benefits of these emollients on skin condition
of younger infants, GA ≤ 27 weeks, infants with Aquaphor® and electrolyte balance.16,17
20 | Pediatric KUSARI ET AL.

Dermatology
such as citrus peels or apple pomace. Although one study shows
3.3.3 | Impermeable and semipermeable plastic
improved skin condition with use of a pectin‐based barrier over the
wraps
first 3 weeks of life,38 pectin adhesive products, as well as those con-
Two broad categories of plastic wraps are sometimes used in the taining hydrocolloid or acrylate adhesive, have the potential to dam-
care of preterm neonates, for different purposes. Impermeable poly- age delicate neonatal skin.39 Use of any medical adhesive in preterm
ethylene wraps have been studied for their utility in reducing heat neonates is associated with medical adhesive‐related skin injury
loss during transportation from the site of birth to the NICU. These (MARSI), which can entail epidermal stripping, tension injury, shearing,
impermeable wraps are intended to be used briefly, typically for a maceration, folliculitis, or contact dermatitis. Epidermal stripping and
matter of minutes. Semipermeable wraps and biopolymers have been skin tears are common forms of MARSI in neonates. In one study
studied in longer time increments for their utility in preventing involving 82 infants (ages 0‐3 months), 45% of infants were found to
TEWL, and maintaining fluid and electrolyte balance. Studies examin- have skin breakdown, of which 17% were skin tears.40
ing these wraps usually involve neonates being cared for in radiant Although repeated application of adhesive dressings has been
warmers rather than humidified isolettes. shown to strip the skin, silicone dressings appear less likely to strip
Maintaining core temperature in preterm neonates during the delicate skin and are associated with less discomfort41 as well as less
minutes following birth remains a challenge. Six studies, involving damage to the stratum corneum than other adhesives in adult
between 55 and 110 neonates each, have examined the effect of infants. For example, one study utilizing electron microscopy shows
short‐term placement in impermeable wraps or garments on tempera- that silicone adhesive disrupts far fewer epidermal cells than acrylate
ture stability. Impermeable wraps have consistently shown to reduce adhesive.42
the incidence of hypothermia, whereas maintaining a warmer delivery In summary, plastic or plant‐based barriers may be used to aug-
room temperature (26°C, 79°F) has not. Preterm infants often require ment the fragile skin barrier of preterm neonates. Impermeable barri-
considerable manipulation in the minutes following birth, including ers appear to reduce risk of hypothermia when used short‐term,
drying and resuscitation. Plastic wraps or bags can help neonates to such as during transport to a NICU. Semipermeable barriers have
retain their body heat, and greater skin coverage with plastic devices been typically studied for days to weeks in conjunction with radiant
appears to be associated with a better outcome. In infants < 28 warmers and can reduce risk of excessive fluid loss and electrolyte
weeks GA, the use of polyethylene occlusive wraps prevents heat imbalance in this setting. Adhesive barriers may offer more consis-
loss after delivery and results in higher NICU admission tempera- tent skin coverage than nonadhesive barriers in day‐to‐day use.
tures31,32 and a lower incidence of hypothermia.33 The 2017 NeoCap However, adhesive barriers (including pectin gel) can strip the skin
study compares post‐stabilization temperature in a group of neonates barrier, causing irritation and worsening transepidermal water loss
bundled in polyethylene body wrap and cap to a group bundled in following removal.
the polyethylene body wrap and a cotton cap. Neonates bundled in
polyethylene body wrap and cap exhibit a higher post‐stabilization
3.3.4 | Sterilization for catheter placement and
temperature than those bundled with a cotton cap.34
procedures
While impermeable wraps are typically used to reduce heat loss
in the minutes following birth, semipermeable wraps have been used Consensus is lacking regarding the preferred antiseptic for use in
chiefly to reduce transepidermal water loss over a span of days or preterm neonates.43 A recent survey of U.S. neonatology program
weeks. Impermeable wraps are typically used with radiant warmers directors show that most institutions (out of those who were sur-
rather than humidified isolettes, the latter of which minimizes TEWL veyed and responded) prefer CHG in preterm neonates (predomi-
through the addition of humidity. A total of seven studies examine nantly without consideration of differing birthweight or gestational
the use of semipermeable wraps in preterm neonates, and the major- age), though some limit use of CHG to > 1000 g or 28 weeks.44
ity of these studies utilize a polyurethane dressing. Two studies uti- Similarly, according to a 2018 survey, CHG is the most commonly
lize adhesive dressings while the remainder use nonadhesive used antiseptic in Canadian NICUs.45
35,36
dressings. These studies show that semipermeable adhesive Some institutions mandate use of povidone‐iodine for catheter
membranes decrease TEWL, reduce skin breakdown, and decrease placement and lumbar puncture for neonates of a certain gestational
erythema while applied, but may strip superficial skin layers when age (< 26‐32 weeks), due to the perception that chlorhexidine is
they are removed, leading to a transient post‐removal increase in more likely to cause burns at younger GA. Clinical thyroid suppres-
34
TEWL. Furthermore, due to their semipermeable design, applica- sion has been reported following administration of povidone‐iodine,
tion of these adhesive membranes does not appear to decrease fluid while chlorhexidine gluconate in its standard 0.5% concentration has
requirement or affect electrolyte status in preterm neonates;35 been found to cause severe chemical burns in preterm neonates.46
however, skin barrier function is disrupted following removal of Some studies suggest 0.2% chlorhexidine gluconate may be an
plastic tape, with increased transepidermal water loss at sites of tape attractive alternative to povidone‐iodine for the very and extremely
removal.37 preterm. One study compares 0.2% chlorhexidine gluconate (CHG)
Another type of adhesive dressing consists of pectin, which is a to 0.5% CHG in extremely preterm infants and shows a statistically
gelling agent extracted from by‐products of fruit juice production, significant decrease in irritant skin lesions in the 0.2% group, without
KUSARI ET AL. Pediatric | 21
Dermatology
an increased risk of central line–associated bloodstream infection though the data are less clear for preterm neonates in developed
(CLABSI).47 As a result of these findings, a randomized trial was countries, given evidence of increased infection risk with petrolatum‐
designed involving 304 preterm neonates in Dublin comparing 0.2% based ointments, as well as evidence of impaired skin barrier matura-
chlorhexidine gluconate in 70% isopropanol to 10% aqueous povi- tion and increased TEWL with sunflower seed oil application.
done‐iodine. Interestingly, the results show no difference in the inci- Antiseptic treatment does not offer a clear benefit over dry cord
dence of catheter‐related bloodstream infection or in skin irritation; care in most studies, though a one‐time treatment with chlorhexidine
however, more thyroid suppression is seen in the povidone‐iodine‐ seems effective. A dilute (0.2%) formulation of chlorhexidine solution
treated group (8% in the povidone‐iodine group vs 0% in the may provide the same benefit as 0.5% chlorhexidine gluconate with
chlorhexidine group).48 More research is needed to assess systemic less irritation. Finally, although povidone‐iodine is an antiseptic com-
effects of CHG and determine definitively whether 0.2% CHG is a monly used in preterm neonates due to the occurrence of severe
viable alternative to povidone‐iodine in preterm neonates. burns with 0.5% chlorhexidine, a more dilute 0.2% chlorhexidine
solution appears to be effective and more suitable for extremely pre-
term skin. Further research is warranted to determine the most
3.3.5 | Cord care
appropriate antiseptic for catheter placement and other procedures
The umbilical cord may be washed with an antiseptic, such as alco- in preterm neonates.
hol, povidone‐iodine, chlorhexidine‐containing solution, or sterile Further studies, particularly in the very preterm and extremely
water. Many practitioners reserve application of antiseptics to the preterm neonates, with an emphasis placed on subclassifying the
cord itself, while cleansing the skin with only sterile water (due to preterm patient population based on gestational age, are needed to
the concern of possible chemical burns). A recent meta‐analysis of further examine and validate the real‐world utility of these interven-
21 studies found that antiseptic treatment (including cleansing with tions. In the meantime, it may be useful to establish practice guideli-
49
alcohol) is comparable to air‐drying the stump with regard to nes based on the evidence we have presented here. Compared to
infection risk, and antiseptic treatment may prolong time to cord term infants, preterm infants possess fragile skin barriers and are
separation.50 Interestingly, one study does suggest that one‐time particularly susceptible to environmental fluctuations and infectious
cleansing with chlorhexidine reduces neonatal mortality when com- assault, and thus are in greater need of appropriate prophylactic and
51
pared to dry cord care; however, most of the existing evidence therapeutic interventions.
suggests that antiseptic treatment does not offer a benefit over dry
cord care.
ACKNOWLEDGMENTS

We thank Dr. Lawrence Eichenfield, M.D., for his careful reading of

4 | CONCLUSIONS this manuscript. We thank Kelly Dillard, R.N., for her insight regard-
ing the real‐world applicability of the major findings of this review.
Our findings summarize the current evidence regarding general skin-
care in preterm neonates and highlight the need for high‐quality
CONFLICT OF INTEREST
research in this area.
The skin barrier in preterm neonates is quite fragile. Preterm skin The authors of this manuscript, listed above, report no affiliation or
matures rapidly after birth, though maturation can take more than involvement with organizations or entities with a financial or non‐
4 weeks in the ultra‐low birthweight.4 Transepidermal water loss is financial interest in the subject matter or materials discussed in this
high and can contribute to dehydration, thermal instability, and elec- manuscript.
trolyte imbalances in premature infants. Based on the available liter-
ature, clinicians can take certain steps to bolster the weak skin
ORCID
barrier and improve the well‐being of preterm neonates.
Humidified incubators are clearly beneficial to preterm neonates, Ayan Kusari http://orcid.org/0000-0003-2100-7407
though in small studies, it appears that 75% humidity is inferior to Allison M. Han http://orcid.org/0000-0001-6702-5163
50% humidity. More research is needed to understand why this is Dawn Z. Eichenfield http://orcid.org/0000-0002-1511-3804
the case—though the added humidity may impede rapid formation
of a waterproof, cornified skin barrier. Preterm neonates can be
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