Considerations Regarding Pressure Injuries of Prematurity in Neonatal Intensive Care Unit

Abstract

Pressure injuries (PIs), also known as pressure ulcers or decubitus ulcers, are a significant concern in neonatal intensive care units (NICUs), especially among premature neonates (Nicolosi et al. 2024). These injuries occur due to prolonged pressure on the skin, leading to tissue ischemia and necrosis. Premature neonates, due to their underdeveloped skin and limited mobility, are particularly vulnerable to PIs. Addressing these injuries is crucial as they can lead to severe complications, including infections, prolonged hospital stays, and even long-term morbidity. We read with great interest the recent article by Dimanopoulos et al. (2024) titled ‘Incidence of hospital-acquired PIs and predictors of severity in a paediatric hospital’. The authors aimed to identify and describe hospital-acquired PIs admission incidence and severity predictors in a large Australian children's hospital. The authors demonstrated that hospital-acquired PIs in paediatric patients are unacceptably high. We are writing to express my interest and highlight the importance of recognizing, preventing and managing PIs in premature neonates within NICUs. We will discuss the unique challenges posed by the fragile skin of neonates, the risk factors associated with PIs, and the current strategies and novel ideas for preventing these injuries, emphasizing the need for neonatal-specific approaches.

PIs are classified into stages based on the severity and depth of the injury, from non-blanchable erythema of intact skin (Stage 1) to full-thickness tissue loss with exposed bone, tendon or muscle (Stage 4) (Nie, Johnson, and Reed 2022). However, the staging system developed for adults may not be directly applicable to neonates, especially preterm infants, due to their unique skin structure. Premature neonates have significantly thinner skin compared to term infants and adults, with the dermal layer being <60% of the thickness of adult skin (Mallick et al. 2023). This immaturity of the skin, combined with the neonates' inability to reposition themselves, makes them highly susceptible to PIs. Moreover, the visual cues used to stage PIs in adults, such as the presence of slough or eschar, may not be as apparent in neonates (Nie, Johnson, and Reed 2022). Thus, the assessment of PIs in this population requires a thorough understanding of neonatal skin development and a careful evaluation of even the smallest signs of tissue damage. The risk factors for developing PIs in neonates can be broadly categorized into extrinsic and intrinsic factors (Mallick et al. 2023). (1) Extrinsic factors include external forces such as shear, friction and prolonged pressure, particularly from medical devices like nasal continuous positive airway pressure masks and endotracheal tubes. The accumulation of moisture from urine, sweat and other bodily fluids further weakens the skin, making it more susceptible to injury. The improper positioning of neonates in NICU beds, which leads to uneven pressure distribution across various anatomical points, also contributes to the development of PIs. (2) Intrinsic factors are related to the neonate's biological characteristics, such as gestational age, birth weight and overall health condition. Premature infants, particularly those born at or before 25 weeks of gestation, are at a higher risk due to their extremely fragile skin and the longer periods they spend in the NICU. The severity of PIs tends to be greater in more mature infants, where injuries can progress to Stage III, involving full-thickness skin loss.

PIs in neonates often present in areas where the skin is in constant contact with medical devices or where pressure is consistently applied, such as the nasal columella, occiput and sacrum (García-Molina et al. 2017; Nie, Johnson, and Reed 2022). The unique clinical presentation of PIs in neonates can include non-blanchable erythema, skin breakdown and in severe cases, deep tissue injury. The pathogenesis of PIs in this population is closely linked to the underdeveloped structure of neonatal skin. The immature stratum corneum and dermis in preterm infants lack the resilience found in older children and adults, making it difficult to assess the depth and severity of PIs accurately. Additionally, the use of non-invasive respiratory support devices, which require a tight fit to prevent air leaks, can cause significant pressure on delicate areas such as the nose, leading to localized tissue damage that may not be immediately visible. Case studies have shown that even minor pressure from these devices can lead to deep-tissue injuries that are challenging to diagnose and treat. Preventing and managing PIs in neonates requires a multidisciplinary approach tailored to the unique needs of this population. Current prevention strategies used in adult care, such as regular repositioning and the use of pressure-relieving mattresses, may not be sufficient or practical for neonates (Mallick et al. 2023). There is a pressing need for neonatal-specific protocols that address the distinct risk factors and vulnerabilities of premature infants. Some proposed strategies include the development of specialized bedding that can reduce pressure on vulnerable areas, the use of protective barriers to prevent device-related injuries, and the careful monitoring of skin integrity, particularly in high-risk areas. Novel ideas such as the design of an antisore bed specifically for neonates have been suggested to minimize the risk of PIs by evenly distributing pressure and reducing friction and shear. Additionally, early identification of PIs through advanced imaging techniques and the implementation of strict infection control measures are critical in managing these injuries and preventing complications.

Implementing effective PI prevention and management strategies in the NICU is fraught with challenges. The current PI staging system, which is primarily designed for adults, may not accurately reflect the severity of injuries in neonates, leading to underdiagnosis or misclassification (Nie, Johnson, and Reed 2022). Furthermore, the fragile condition of premature infants often limits the interventions that can be safely performed, such as frequent repositioning or the use of certain protective devices. Ethical considerations also play a significant role, as the balance between providing necessary medical support and preventing PIs can be difficult to achieve. Additionally, the need for specialized training for NICU staff in the prevention and management of PIs is paramount. Staff must be equipped with the knowledge and skills to identify early signs of PIs, understand the unique skin structure of neonates, and apply appropriate interventions. To improve the prevention and management of PIs in neonates, further research is needed to develop a PI staging system tailored to the neonatal population (Nie, Johnson, and Reed 2022). This system should account for the unique characteristics of neonatal skin and the specific challenges posed by the use of medical devices in this population. Additionally, research should focus on the long-term outcomes of neonates who suffer from PIs, including the potential for scarring and other complications later in life. Interdisciplinary approaches that involve neonatologists, dermatologists, nurses and biomedical engineers are essential to develop effective solutions for preventing and treating PIs in neonates (Mallick et al. 2023; Nie, Johnson, and Reed 2022). The development of innovative products, such as pressure-relieving devices and advanced wound care materials, should also be a priority.

In conclusion, PIs in premature neonates are a significant and complex challenge in NICU settings. The unique vulnerabilities of this population necessitate the development of specialized prevention and management strategies. While current practices borrowed from adult care provide a starting point, there is an urgent need for neonatal-specific approaches that address the distinct physiological and anatomical characteristics of neonates. By advancing research and implementing tailored interventions, we can improve the outcomes for these vulnerable patients and reduce the incidence and severity of PIs in NICUs.

Jinjing Zhou, Lehui Ying, Mading Zhao and Zhihui Wang: conceptualization, supervision, validation, writing – review and editing. All authors provided final approval for publication.

The authors have nothing to report.

The authors declare no conflicts of interest.