Chronological evaluation of functional changes in neonatal skin: A temporal evaluation of skin maturation

Abstract

Preterm skin is immature, lacking many functional and structural qualities. Hospital acquired skin breakdown in preterm neonates poses challenges in intensive care and can be a source of pain and infection. Much of the evidence to inform promotion of skin health is adapted from research in adults or older children, leaving a gap in knowledge, which limits care strategies for these vulnerable babies. This research study aimed to identify structural and physiological characteristics of skin in extreme preterm babies and to evaluate these changes with time. This was a longitudinal cohort study of preterm and term infants admitted to NICU in a single large University Hospital. Transepidermal water loss (TEWL), pH. dermal characteristics using high frequency ultrasound imaging (HFUSI) were measured serially and evaluated with gestational age, birth weight, ambient conditions, nutrition, and medications.
Preterm (n=39, median GA 27+4) and Term infants (n=20) were recruited over 18 months. The birth weight of the recruited babies ranged from 500-4230g. TEWL water loss at <48h of age was inversely related to GA (rs = -0.69, p < 0.01) and birth weight (rs = -0.53, p = 0.001). Time to reach functional stratum corneum maturity was influenced by GA at birth and incubator humidity. The correlation of skin pH with gestational age was not significant (rs = -0.30 p = 0.073). Qualitative analysis of ultrasound pictures revealed clear delineation of skin layers in term and late preterm babies (>27+6 weeks GA) soon after birth, but not in extreme preterm babies (GA <28 weeks) till at least 3 weeks of age. Dermal thickness in <28week infants continued to be significantly less than term infants after 8 weeks postnatal age while total skin thickness and dermal echogenicity were matched with those in term infants. This is the first study to show functional maturation in the dermal-epidermal layers in extreme premature infants, by revealing the structural and functional changes in skin in the early weeks of life.
Research and clinical implications
Future research could include use of histological comparison of skin structure with physiological maturity and structural dermal characteristics of skin as noted on ultrasound analysis. This will provide guidance for individualised intensive care strategies for extreme preterm babies for example ambient incubator humidity, ability to endure device related stress produced by the non-invasive device interfaces and other intensive care practices involving nutrition and skin-to-skin care.

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ORCID for Pete Worsley: orcid.org/0000-0003-0145-5042

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