Background: NICU patients are at risk of skin breakdown due to prematurity, irritant exposure, medical status and stress. There is a need to minimize damage, facilitate skin development and reduce infection risk, but the literature on the effects of skin care practices in NICU patients is limited. Objectives: To test the hypothesis that baby diaper wipes with emollient cleansers and a soft cloth would minimize skin compromise relative to cloth and water. Methods: In 130 NICU infants (gestational age 23–41 weeks, at enrollment 30–51 weeks), measurements of skin condition, i.e., skin erythema, skin rash, transepidermal water loss (TEWL) and surface acidity (pH), within the diaper and at diaper and chest control sites were determined daily for 5–14 days using standardized methods. Treatments were randomly assigned based on gestational age and starting skin irritation score: wipe A, wipe B, and the current cloth and water NICU standard of care. Results: Perineal erythema and TEWL were significantly lower for wipes A and B than cloth and water beginning at day 5 for erythema (scores of 1.11 ± 0.05, 1.2 ± 0.05, and 1.4 ± 0.06, respectively) and day 7 for TEWL (28.2 ± 1.6, 28.8 ± 1.6, and 35.2 ± 1.6 g/m²/h, respectively). Wipe B produced a significantly lower skin pH (day 5, 5.47 ± 0.03) than wipe A (5.71 ± 0.03) and cloth and water (5.67 ± 0.04). The starting skin condition, stool total, age and time on current standard impacted the outcomes. Conclusions: Both wipes are appropriate for use on medically stable NICU patients, including both full and preterm infants, and provide more normalized skin condition and barrier function versus the cloth and water standard. Wipe B may facilitate acid mantle development and assist in colonization, infection control and barrier repair. Neonatal skin continues to change for up to 8 weeks postnatally, presumably as it adapts to the dry extra-uterine environment.

Pressure ulcers (PU) are serious, reportable events causing pain, infection and prolonged hospitalization, particularly among critically ill patients. The literature on PUs in neonates is limited. The objective was to determine the etiology, severity and influence of gestational age on PUs among hospitalized infants. A two-year prospective study was conducted among 741 neonatal intensive care patients over 31,643 patient-days. Risk factors were determined by comparing the characteristics of infants who developed PUs with those who did not. There were 1.5 PUs per 1000 patient days with 1.0 PU per 1000 days in premature infants and 2.7 per 1000 days in term infants. The number of PUs associated with devices was nearly 80% overall and over 90% in premature infants. Infants with PUs had longer hospitalizations and weighed more than those who did not. Infants with device-related PUs were younger, of lower gestational age and developed the PU earlier than patients with PUs due to conventional pressure. The time to PU development was longer in prematurely born versus term infants. Hospitalized neonates are susceptible to device-related injury and the rate of stage II injury is high. Strategies for early detection and mitigation of device-related injury are essential to prevent PUs.

BACKGROUND AND OBJECTIVE: Pediatric patients are at risk for developing pressure ulcers (PUs) and associated pain, infection risk, and prolonged hospitalization. Stage III and IV ulcers are serious, reportable events. The objective of this study was to develop and implement a quality-improvement (QI) intervention to reduce PUs by 50% in our ICUs. METHODS:We established a QI collaborative leadership team, measured PU rates during an initial period of rapid-cycle tests of change, developed a QI bundle, and evaluated the PU rates after the QI implementation. The prospective study encompassed 1425 patients over 54 351 patient-days in the PICU and NICU. RESULTS:The PU rate in the PICU was 14.3/1000 patient-days during the QI development and 3.7/1000 patient-days after QI implementation (P , .05), achieving the aim of 50% reduction. The PICU rates of stages I, II, and III conventional and device-related PUs decreased after the QI intervention. The PU rate in the NICU did not change significantly over time but remained at a mean of 0.9/1000 patient-days. In the postimplementation period, 3 points were outside the control limits, primarily due to an increase in PUs associated with pulse oximeters and cannulas. CONCLUSIONS:The collaborative QI model was effective at reducing PUs in the PICU. Pediatric patients, particularly neonates, are at risk for device-related ulcers. Heightened awareness, early detection, and identification of strategies to mitigate device-related injury are necessary to further reduce PU rates. Pediatrics 2013;131:e1950-e1960 Dr Visscher made a substantial contribution to the conception and design, acquisition of data, and analysis and interpretation of data and in drafting the article with critical revision for important intellectual content; Dr Leung made a substantial contribution to the design, analysis, and interpretation of data and in drafting the article with critical revision for important intellectual content; Mss Nie, Schaffer, and Taylor, Dr Pruitt, and Ms Giaccone made substantial contributions to the conception and design, acquisition of data, and interpretation of data; Mr Ashby made a substantial contribution to the conception and design, analysis of data, and interpretation and in drafting of article with critical revision for important intellectual content; Dr Keswani made a substantial contribution to conception and design, analysis and interpretation of data and in drafting the article with critical revision for important intellectual content; and all authors had final approval of the version to be published. Stage III and IV PUs are serious reportable events, considered "never events" by several national benchmarking organizations. 5 PU incidence is higher in critically ill patients, 6 with increased pain, infection, and prolonged hospitalization. 7 Reductions in reimbursement for health care-acquired PUs have been implemented by the Centers for Medicare & Medicaid Services for adult institutions. 8 They extend to Medicaid recipients, including pediatrics, as of July 2...

Premature infants with early stool contact and high exposure, full term infants, and patients with congenital diaphragmatic hernia or trisomy 21 are at high risk for skin compromise and may benefit from prophylactic interventions to minimize compromise. Low stool exposure and greater time before the first stool contact appear to be protective against skin compromise.

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