Art & science tissue viability supplement
Wound care considerations
in neonates
Cousins Y (2014) Wound care considerations in neonates.
Nursing Standard. 28, 46, 61-70. Date of submission: October 6 2013; date of acceptance: March 12 2014.
Abstract
Wound care management is a complex issue when caring for the
neonate. An understanding of the anatomy and physiology of
neonatal skin is necessary to recognise and prevent any potential
problems. Effective wound care is a dynamic process based on
accurate assessment and the setting of realistic goals. Knowledge of
the specific characteristics of neonatal skin and the wound healing
process is required when determining appropriate treatment and
selecting wound care products.
Author
Yvonne Cousins
Neonatal surgical nurse specialist, Neonatal Unit, Evelina London
Children’s Hospital, London.
Correspondence to: yvonne.cousins@gstt.nhs.uk
Keywords
Assessment, debridement, neonatal skin, neonate, wound care,
wound care products, wound healing, wound infection
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WOUND MANAGEMENT PRESENTS
significant challenges to the neonatal nurse.
The skin of the neonate – a baby within the first
28 days of life – is immature in structure and
vulnerable to injury, with wound healing often
compromised by the general physiological status.
Neonates are particularly at risk of sepsis because
of their immature immune system, placing them at
risk of secondary infection as a result of bacterial
proliferation within the wound bed.
Wound management practices need to be
underpinned by an understanding of the anatomy
and physiology of neonatal skin, the mechanisms
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of skin injury and the physiology of wound
healing. Wound assessment, pain assessment
and management, and support of the family are
integral to this process. Safe delivery of care also
requires knowledge of the various wound care
products available, and their suitability for the
neonatal wound.
Anatomy and physiology of the skin
The functions of the skin include protection,
maintenance of fluid and electrolyte balance,
and thermoregulation. The skin also acts as a
tactile receptor. Skin comprises the epidermis and
dermis, with a subcutaneous layer of fat between
the skin and underlying structures. The outer
layer of the epidermis is the stratum corneum,
which plays a vital part in the skin’s barrier
function (Tortora and Grabowski 2002), and
consists of corneocytes and a mixture of lipids,
known as the lipid lamellae. The corneocytes
contain hyaluronic acid, glycerol and natural
moisturising factor, which attract and hold water
within the cells. The corneocytes are held together
by corneodesmosomes, which are broken down
by proteases in the process of desquamation.
Desquamation helps to maintain the thickness of
the stratum corneum (Cork and Danby 2009).
Maturation of the stratum corneum takes place
in the third trimester, continuing up to one year of
life (Nikolovski et al 2008). The stratum corneum is
approximately 30% thinner in an infant compared
with an adult (Dyer 2013). The reduced barrier
function of the stratum corneum places the neonate,
and especially the preterm neonate, at risk of variable
transepidermal water loss, leading to dehydration
and electrolyte imbalance, percutaneous toxicity,
and microbial colonisation (Lawton 2013).
Skin pH is also important in skin barrier
function. The pH of skin at birth is greater than
6, and reduces to 5.4-5.9 over the first few days of
life, providing an ‘acid mantle’ that stabilises the
lipid lamellae and skin hydration, and controls
microbial colonisation (Lio et al 2011, Ness et al
2013). This acidification can be delayed in very
immature neonates (Fox et al 1998).
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Art & science tissue viability supplement

At term, the epidermis and dermis, despite being
structurally similar to the adult, are 30% thinner
than that of the adult (Campbell and Banta-Wright
2000). The junction between them is fragile,
with risk of injury from adhesive removal and
blistering from friction (Baharestani 2007). The
dermis, which consists of elastin fibrils, collagen,
fibrous protein, nerves, blood vessels, sebaceous
glands, and hair follicles, provides nutritional and
physical support to the epidermis (Burr and Penzer
2005). Collagen develops in the dermis in the final
trimester, and lack of collagen places the preterm
neonate at risk of becoming oedematous, putting
the skin at risk of injury (Wilcinski 2010).
Neonatal wounds
The neonatal nurse has an important role in
the prevention and identification of iatrogenic
injuries, and these wounds and guidance for their
management are summarised in Table 1. Skin
assessment allows for an objective analysis of skin
condition, identifying those neonates at risk of skin
breakdown, and thereby enabling a plan of care to
be put in place. Several skin assessment tools are
available, but only a few are specific to neonates,
such as the Neonatal Skin Risk Assessment Scale
(Huffines and Logsdon 1997, Dolack et al 2013).
and treatment strategies used will differ (Parnham
2012). Moisture lesions may develop over bony
prominences, within skin folds, the anal cleft, or
the perianal area. They are usually irregular in
shape, or of a linear shape in cleft and skin folds,
red in colour with pink or white maceration, and
superficial with partial thickness skin loss. Pressure
ulcers are often a regular shape limited to one spot.
They can vary in thickness with necrosis present
in full-thickness pressure damage, and in colour
from red to yellow, green and black (Defloor et
al 2005). Pressure ulcers require the reduction or
relief of pressure, whereas to prevent moisture
lesions the skin needs to be kept clean, dry, and
well hydrated. Pressure ulcers and moisture lesions
can present as a combined lesion with elements
of both pressure and moisture damage (Fletcher
2008). The European Pressure Ulcer Advisory
Panel and National Pressure Ulcer Advisory Panel
(2009) classification system is recommended for
classifying pressure ulcers.
Diaper dermatitis
Diaper (nappy) dermatitis (Figure 1) is one of
the most common dermatological conditions
experienced by neonates, with a prevalence of
between 4% and 15% (Ness et al 2013). The
most common causes are irritant dermatitis

Pressure ulcers and moisture lesions

Pressure ulcers develop where there has been FIGURE 1
starvation of oxygen and vital nutrients, as a Diaper (nappy) dermatitis in female infant (a)
result of soft tissue being compressed between a and male infant (b)
bony prominence and an external surface (Bryant
and Nix 2012). Risk factors for the preterm a)
and/or sick neonate include the immaturity and
underdevelopment of the epidermis, the reduced
subcutaneous layer, oedema, immobility and
hypotension (McGurk 2004). It has been reported
that 50% of pressure ulcers in neonates are related to
equipment and devices (Ness et al 2013). Common
sites include the occiput, ears, nares and nasal
septum where hats and tapes are employed to secure
ventilatory devices and feeding tubes (Table 1).
Assessment of risk and frequent skin assessment
are essential elements of pressure ulcer prevention
(Parnham 2012). However, there is a lack of
b)
evidence-based research to formulate guidelines
for clinical practice, and for the neonate in
particular, there is a need to identify age-related
preventive strategies (Baharestani and Ratcliff
SCIENCE PHOTO LIBRARY

2007). A systematic review of paediatric pressure

ulcer risk assessment scales concluded that clinical
judgement may be more effective in evaluating
pressure ulcer risk (Kottner et al 2013).
It is important to differentiate between moisture
lesions and pressure ulcers, since the prevention

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Art & science tissue viability supplement

and Candida, with hydration, elevated pH and
a compromised water barrier function of the
skin contributing to the pathophysiology
(Stamatas et al 2011, Ravanfar et al 2012).
Diaper dermatitis presents as erythema, which
can deteriorate to include maceration, erosions
and ulceration, and can involve the buttocks,
genitalia, lower abdomen, and upper thighs
(Humphrey et al 2006).
Water alone is a poor cleanser of oil-soluble skin
surface impurities because it raises the skin pH
from 5.5 to 7.5 and can cause dryness. Traditional
soaps tend to be alkaline, irritating the skin and
leading to dryness (Kuehl et al 2003, Blume-
Peytavi et al 2009, Lawton 2013). However, the
advice regarding skin cleansing and nappy area
care is conflicting. A consensus conference of
European Dermatologists and Paediatricians on

TABLE 1
Neonatal wounds and management guidance
Neonatal skin Wound type Management guidance
physiological risk
factor
Epidermis Chemical burns Aqueous based skin preparations for cleansing.
 Reduced stratum injury, for example Limited skin exposure to cleansing agents.
corneum leading as a result of Rinse off cleansing agent with sterile water.
to reduced barrier skin preparation Avoidance of known irritants.
function. cleansers such as
chlorhexidine.
Diaper dermatitis. Frequent nappy changes, or nurse infant exposed without nappy.
Thin layer of barrier cream, for example white soft paraffin.
Use mild, pH neutral liquid cleansers with caution.
Dermis Adhesive injury such Adhesives should be used sparingly, and not reapplied to the same area.
 Reduced elastin as skin stripping Consider using Velcro strapping, foam dressings or stretchy dressings to secure
fibrils. as a result of tape equipment and primary dressings but take care not to add additional pressure.
 Reduced collagen. removal.
Use of barrier films and silicone dressings and tapes, according to manufacturer’s
recommendations.
Use thin hydrocolloid dressings in vulnerable areas such as beneath intravenous
(IV) cannula wings.
Use of the horizontal stretch method for thin adhesive dressing removal.
Use of an approved neonatal plaster remover, or water-soaked cotton wool,
or sunflower seed oil.
Dermis Pressure ulcers. Careful handling.
 Reduced elastin Ischaemic injuries. Regular repositioning and skin risk assessment as appropriate.
fibrils. Friction injuries, for Care of positioning and resiting of equipment such as tubes, facial masks, nasal
 Reduced collagen. example with an cannulae, leads, intravenous (IV) cannula wings, sensors, and probes.
And: Reduced agitated infant. Care of clothing and tapes, loosen if possible.
subcutaneous layer
(particularly in the Pressure relieving aids, for example gel mattresses and pads.
preterm infant).
Thermal injury, Reduced temperatures and application times for monitoring devices.
for example from Minimal exposure time to light sources.
monitoring devices.
Fragile and Extravasation injury. Careful siting and confirmation of initial IV cannula placement.
small-calibre veins, Sterile transparent dressing to secure cannula with good visibility at all times, and at
reduced strength least hourly inspection.
and support
IV fluids administered by infusion pumps with lumen pressure monitoring specifically
from connective
designed for neonates.
tissue and skin,
and prolonged Administer glucose >10%, calcium, total parenteral nutrition, hypertonic solutions
intravenous therapy. and inotropes via a central venous catheter.
Risk scoring to define the severity of extravasation injury (Schie and Goodman 2013).
(Adapted from Irving et al 2006)

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newborn skin care confirmed the possible benefit
of liquid cleansers containing emollient, but
emphasised the need for further research into their
potential benefits (Blume-Peytavi et al 2009).
Emollients Emollients cleanse and hydrate the
skin, and have a fundamental role in skin care
(Lawton 2013). They have several modes of
action that lead to protection of the stratum
corneum, and formation of a healthy, functional
epidermal barrier (Ness et al 2013). Emollients
should be differentiated from aqueous cream
and moisturisers. Aqueous cream was designed
to be washed off, and has been shown to have
a detrimental effect on skin barrier function,
exacerbating atopic eczema (Mohammed et
al 2011, Medicines and Healthcare products
Regulatory Agency 2014). Moisturisers add
moisture as compared with emollients which
draw moisture into the stratum corneum, or
trap moisture, thereby softening the skin (Lawton
2013). White soft paraffin is frequently used
with neonates; however, care should be taken
when using an emollient as it may contain added
ingredients such as lanolin alcohol that may cause
sensitivity (Hoath and Narendran 2000).
Several studies have examined the effect of
various oils on the skin, and associated infection
rates (Danby et al 2013, Lawton 2013). While
there is now evidence that does not support the use
of olive oil, as a result of its potential to promote
the development of atopic eczema (Danby et al
2013), sunflower seed oil has been found to have a
positive effect on skin barrier recovery (Darmstadt
et al 2002). It has also been linked with significant
health improvements in preterm neonates in
resource-poor countries where it has a significant
role in preventing infection (LeFevre et al 2010,
Duffy et al 2012). However, further studies into
the use of oils as emollients are required.
Studies evaluating baby wipes are limited,
and those that are available do not suggest
associated skin injury or irritation (Ness et al
2013). Disposable baby wipes should be avoided
in the first month of life (Jackson 2008, Hughes
2011). A barrier paste, such as white soft paraffin,
applied in a thin layer over the nappy area will
help to prevent irritation and over-hydration
(Hughes 2011).
Extravasation injury
The most common iatrogenic injury to the skin
and underlying tissues in neonates is extravasation
injury (Reynolds 2007). These injuries are a
result of intravenous (IV) fluid unintentionally
leaking into the surrounding tissues, which can
lead to scarring, infection, necrosis, contractures,
and the need for plastic surgery. The neonate,
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and particularly the preterm neonate, is at risk
because of the small calibre of the veins, the lack
of supporting connective tissue, and the need for
administration of total parenteral nutrition and
other high osmolality infusions such as antibiotics.
Signs of extravasation include swelling, erythema,
leakage of fluid, and blanching of the overlying
skin (Ness et al 2013). Preventive measures are
provided in Table 1.
There is no gold standard for the treatment of
neonatal extravasation injuries, and prevention
is vital to management. Management depends
on the severity of the injury, but may include
removing the extravasant. This is a painful,
invasive procedure that carries the risk of
causing further tissue damage. Although this
procedure has had widespread use, its benefit,
compared with conservative management, is
not supported by an adequate evidence base
(Reynolds 2007). Other treatments to optimise
the initial management of extravasation include
the use of different dressings and hydroactive gels,
non-contact low-frequency ultrasound (Schie
and Goodman 2013), and limb elevation, which
reduces oedema (Pantelides and Shah 2013). Any
dressings used should be chosen according to
management objectives.
Wound healing
Wound healing consists of four overlapping
stages: haemostasis, inflammation, proliferation
and repair, and maturation and remodelling (Fox
2011). Following injury, the clotting cascade
initiates haemostasis with platelet aggregation
and clot formation, closely followed by the
inflammatory response. This is characterised
by the removal of cellular debris and infectious
agents by neutrophils, macrophages and
monocytes. New blood vessels are formed, vessels
dilate and permeability increases, leading to fluid
leaking into the wound (Wilcinski 2010).
Granulation tissue consisting of new
epithelium, connective tissue and capillaries is
formed, and collagen is created by fibroblasts,
keeping the wound moist and assisting healing.
As the collagen, capillaries and cells begin to fill
the wound space, the myofibroblasts align along
the lines of contraction, so that the area decreases
in size with granulation tissue. Epithelial cells
migrate from surrounding skin across the wound
bed, and differentiate into the layers of the dermis
(Wilcinski 2010). Wound healing occurs faster
in neonates compared with the adult population,
because of the presence of a greater number
of fibroblasts during this process (Baharestani
2007). The final stage involves the reorganisation
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Art & science tissue viability supplement
and modelling of collagen, with an increase in
strength of the scar tissue (Taquino 2000).
Healing is compromised by anything that
disrupts this process. Adequate tissue perfusion
is essential for triggering haemostasis, and for
transportation of the healing factors, substrates
and oxygen to tissues (Fox 2011), while tissue
hypoxia disrupts phagocytosis, impairs collagen
synthesis, increases collagen lysis, and decreases
epithelial proliferation and migration (Wilson
et al 2005). Infection, impaired coagulation,
physiological instability, poor nutritional status
and treatments with corticosteroids affect wound
healing (Fox 2011).
Wound assessment
Wound assessment, and the planning and
evaluation of care provide structure to the
management of the wound care process. It
enhances communication between healthcare
professionals, assists in decision making and
enables audit of the process (Fox 2011). It is
important that it enables the nurse to monitor
the healing process, recognise the stage of
healing, and be guided in what to do next
(Greatrex-White and Moxey 2013). Criteria
for inclusion within the wound assessment are
provided in Table 2.
Documentation is necessary for recording
and communicating the progress of wound
healing (Greatrex-White and Moxey 2013).
Nursing and Midwifery Council (2009)
TABLE 2
Criteria for inclusion within a wound assessment
Criteria Details
 Infant details Age, history, physiological status and
surgical history, as appropriate.
 Wound Duration.
characteristics Size: length, width and depth.
Exudate: type, quantity, colour and odour.
State of wound bed: necrotic, sloughy,
granulating and/or epithelializing.
Periwound skin condition.
 Pain Pain assessment using validated pain
assessment tool.
 Signs of infection Dehiscence, heat, swelling, pain, erythema,
oedema, friability and increasing exudate are
signs of systemic infection.
(Adapted from Greatrex-White and Moxey 2013)
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guidance on record keeping outlines the
requirement that nurses maintain accurate
records that can be communicated effectively
within the multidisciplinary team. Photographic
documentation, with parental consent, is useful
for providing evidence of the state of the wound
over a period of time (Hess 2005).
Pain
Pain assessment and management are essential
to wound care because, in addition to discomfort
for the infant, pain and stress can cause
vasoconstriction, which will impair healing (Fox
2011). It is important that the nurse can identify
physiological signs such as increased heart rate
and blood pressure, variations in respiratory rate
and decreased oxygen saturation and behavioural
cues such as crying, irritability, facial expression,
behavioural state and body posture indicating
pain. Research has shown that neonates exhibit a
more prolonged stress response than adults, and
preterm neonates may actually be more sensitive to
pain (Coleman et al 2002). Non-pharmacological
interventions, such as non-nutritive sucking with
sucrose, may be adequate for a short duration
(Naughton 2013); however, pharmacological
treatments such as paracetamol and opioids may
need to be used (Irving et al 2006).
Infection
Most wounds are colonised with bacteria
with no obvious effect on the wound healing
Rationale
To be aware of factors affecting healing: physiological
instability, inadequate perfusion, impaired coagulation,
poor nutritional status and medications, for example
Corticoststeroids.
Reduction in size is an indicator of healing.
Increase in volume or viscosity of exudate may indicate
infection or impending dehiscence.
Indication of stage of wound healing.
Deterioration may indicate further tissue damage, induration
or cellulitis may indicate infection, and maceration may
suggest wound not being managed effectively.
Pain management is essential for overall condition of
infant. Increasing pain may indicate infection.
Infection delays healing, increasing morbidity and
mortality.
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process. When the relationship between the
host and bacteria becomes unbalanced, the
wound begins to show signs of delayed healing.
Bacteria compete with host cells for nutrients and
oxygen, prolonging the inflammatory response,
and producing proteases and toxins (Fox 2011).
The infected wound will show signs of delayed
healing, heat, pain, oedema, discharge and wound
breakdown (Scanlon 2005). Chronic wounds
which appear to be stuck in the inflammatory
stage of healing can be confused with infection
(Sibbald et al 2003). The neonate is at risk of
further tissue destruction because of its moderately
effective inflammatory response which is not yet
well differentiated (Newnam and McGrath 2010).
Surgical wounds
A surgical wound will be covered with a dressing
of the surgeon’s preference. The length of time the
initial surgical wound dressing remains in place
is controversial. A Cochrane review concluded
that there was no detrimental effect on outcome
when dressings were removed within 48 hours,
however, because this was based on low quality
evidence from four small randomised controlled
trials, the authors suggested the need for further
research (Toon et al 2013). Regular observation
of the wound for signs of infection or dehiscence
– separation of the edges of the incision – should
be made. Signs of impending dehiscence include
inflammation and oedema of the wound and
around the wound site, drainage from the wound
and systemic infection (Hunter et al 2007).
Wound care products
Knowledge of the characteristics of neonatal
skin, the nature of the wound and objectives of
wound assessment should direct the choice of
wound dressing. A dynamic approach needs to
be taken as the condition of the wound changes,
with secondary objectives occasionally required
(Fox 2011). Tissue viability nurses are a source
of knowledge and support, and can provide
leadership in the wound care process. A detailed
knowledge of the wound care product being used
is required, particularly the ingredients and their
potential percutaneous absorption (McCord and
Levy 2006). The choice of appropriate product can
be difficult for several reasons, including the large
number of products available (McKeeney 2011).
Dressings should provide protection to the
wound and assist wound healing. They should be
able to be cut to size, be easy to apply and remove,
be able to be used in a humidified environment,
and require infrequent changes (Baharestani
2007). Analgesia should be given before the
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procedure, and given time to take effect. The
dressing procedure should use an aseptic
non-touch technique (National Institute for Health
and Care Excellence 2008), and should be well
planned and prepared, and performed in a warm,
quiet, calm environment, thus reducing the risk
of thermoregulatory stress, environmental stress
and further pain for the infant. Best practice
indicates the need for two people to carry out the
procedure: one to comfort the infant, while the
second person performs the procedure (Irving et
al 2006). In addition, parents may require support
and reassurance, and explanations of the rationale
for the wound care, and they may also wish to be
actively involved in this care.
Wound cleansing
Wound cleansing is important to wound bed
preparation because the presence of necrotic tissue,
slough and bacterial contamination will delay
wound healing (Irving et al 2006). Cleansing
agents need to be warmed as cold cleansing agents
will cool the wound bed, reducing polymorphic
and macrophagic activity (Irving et al 2006). The
frequency of cleansing the wound will depend on
the characteristics of the wound and the type of
dressing used. 0.9% sodium chloride, warmed to
body temperature, is commonly used to cleanse the
wound in a neonate. Pharmacological preparations
such as Prontosan Wound Irrigation Solution
(Bradbury and Fletcher 2011) have been used on
chronic neonatal wounds, although only selectively
according to the manufacturer’s recommendations.
These products disrupt the biofilm – microbial
communities that delay healing and infection
because of the protease activity and immunological
suppression, which exist within the wound
resulting in positive outcomes (Percival et al 2012).
Debridement
Debridement is the removal of devitalised or
infected tissue, for example slough and necrotic
tissue, or foreign material from a wound,
thereby reducing the bacterial burden that
extends the inflammatory phase and impairs
epithelialisation (Ousey and McIntosh 2010).
Autolytic debridement, often used with neonatal
wounds, relies on a warm, moist environment
maintained by the use of wound dressings. This
allows macrophages to break down proteins
retaining the necrotic tissue, and stimulates
neutrophils promoting granulation (Anderson
2006). Suitable dressings for this process with the
neonate include moisture retentive transparent
dressings, for example Tegaderm Film, and thin
hydrocolloids, for example DuoDERM Extra Thin
Dressing, which promote wound moisture and
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Art & science tissue viability supplement
also provide a waterproof and bacterial barrier
(Baharestani 2007). Choice of adhesive dressing
will be dependent on the integrity of the skin and
predicted wear time.
Topical products containing honey are being
used increasingly in the treatment of neonatal
wounds. Honey exhibits antibacterial, anti-
inflammatory and antiviral properties. It provides
an autolytic debriding effect, stimulating growth
and healing in dormant wounds – wounds failing
to heal – and it stimulates anti-inflammatory
activity, which reduces pain, oedema and exudate.
However, because of limited research into the use
of honey and wound management in paediatric
applications, further research is needed
(Bittmann et al 2010).
Care of the periwound
Preventing skin breakdown of the periwound is
important to the wound healing process (McCord
and Levy 2006). Guidelines recommend the use of
pectin or hydrocolloid barriers such as DuoDERM
Extra Thin Dressing (ConvaTec) or barrier films
such as Cavilon No-Sting Barrier Film, which are
recommended for use in infants over 30 days of age
(McNichol et al 2013). However, further research
is needed on the use of barrier films in neonates
(McNichol et al 2013).
Dressing selection
When choosing the appropriate dressing, the
amount of exudate is an important factor. Exudate
is normally clear or amber coloured, but variations
in colour, consistency, odour and amount can
indicate changes to the healing process, and should
alert the nurse to potential infection (Adderley
2010). Appropriate for neonatal use are dressings
consisting of carboxymethylcellulose hydrofibres,
for example Aquacel dressing, which absorb
wound exudate and maintain wound moisture,
enabling autolytic debridement (McCord and
Levy 2006). However, care needs to be taken to
ensure that the dressing does not dry out if there
is a reduction in exudate, or evaporation from the
necessary secondary dressing.
Composite dressings are useful in exudate
management, and can function as either a primary
or a secondary dressing on a variety of wounds (Fox
2011). These dressings consist of multiple layers
providing absorption, adhesion and a bacterial
barrier, and may also include an adhesive border
of non-woven fabric tape or transparent film, for
example Tegaderm +Pad film dressing (Fox 2011).
New technology has resulted in the introduction
of silicone dressings such as Adaptic Touch and
Mepilex Border Lite (Morris et al 2009). When
used as a primary dressing, they allow exudate
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to pass through to the secondary dressing,
reducing the risks of maceration (Morris et al
2009). Silicone dressings lack adhesive and permit
atraumatic removal of the dressing (Morris et al
2009). These dressings are effective with unusually
shaped wounds in difficult locations, making them
particularly useful for neonatal wounds (Cutting
2008, Morris et al 2009). Limited evidence
suggests that silicone adhesives are gentler and
associated with lower risk of skin injuries because
of their lower surface tension, which remains
constant over time, and their ability
to be repositioned (McNichol et al 2013).
Silver-impregnated dressings with antimicrobial
properties have been used successfully with
neonates, including preterm neonates, to treat
wounds such as abdominal wall dehiscence,
infections and chemical burn injuries (McCord et
al 2004, Rustogi et al 2005). However, it has been
suggested that because the effect of absorption
of silver is unknown in neonates, these products
should not have prolonged use, should only be used
where there is adequate renal function, and the
product with the lowest amount of silver should be
used (McCord and Levy 2006).
When removing thin adhesive dressings, the
horizontal stretch method should be used whereby
the adhesive is gently peeled using parallel force.
Care should be taken with the use of adhesive
removers as many solvents contain hydrocarbon
derivatives or petroleum distillates, which can
cause toxicity through percutaneous absorption
(Baharestani 2007). Simple water-soaked cotton
wool balls, sunflower seed oil and emollients may
be equally effective for adhesive removal (Ness et
al 2013). Silicone-based adhesive removers such as
Appeel Sterile sachet are appropriate for neonatal
use as they are sterile, gentle, not metabolised by the
skin and leave no residue on the skin (Denyer 2011).
Negative pressure wound therapy
Negative pressure wound therapy (NPWT) aims
to assist wound healing by reducing oedema
and infection, promoting tissue granulation and
shortening the time necessary for wound closure
(Stoffan et al 2012). Several clinical reviews have
been published, supporting its use in neonatal
wounds (Baharestani et al 2009). It is being used
increasingly in the treatment of complicated
chronic neonatal wounds, such as dehisced
surgical wounds, pressure ulcers, extremity
wounds, wounds with fistula and complex
abdominal wall defects (Arca et al 2005, McCord
et al 2007, Wilcinski 2010). NPWT involves the
application of a dressing to the wound bed, which
is attached to a specialised pump creating negative
pressure (Wilcinski 2010). Negative pressure
© NURSING STANDARD / RCN PUBLISHING
of -75mmHg has been suggested for congenital
abdominal wound management, and -50 to
-75mmHg for other wounds (Baharestani et al
2009). The periwound skin needs to be protected
from the effects of maceration by the exudate,
potential friction injury caused by removal of the
dressing, and pressure injury from the NPWT
apparatus (Lopez et al 2008). The pressures used,
the frequency of dressing changes and the length of
time it is in use will depend on the condition of the
wound bed.
Conclusion
Maintenance of skin integrity in neonates is crucial
for survival. The sick neonate is particularly at risk
of injury as a result of the fragile and immature
state of the skin, the immature immune system,
general physiological status, and the care and
treatment the skin requires. Best practice when
providing wound care consists of an understanding
of the wound healing process and the factors
affecting healing, a dynamic wound assessment
process, knowledge of the different wound care
products available, effective pain management,
good documentation and effective communication
between healthcare professionals and the family.
The evidence base for neonatal wound care is
limited, and although the guiding principles of
adult wound care are applicable, there is a need
for ongoing research into neonatal wound care to
provide safe and effective care NS

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