Addressing the Pain: Adapting a Soft Silicone Dressing to Enhance Infant Outcomes

    In the quest to maintain skin integrity, reduce pain, and improve outcomes for preterm infants (babies born before 37 weeks gestation¹), neonatal intensive care clinicians must balance technology with tissue protection. Protecting the nasal septum and perinasal tissue during the course of continuous positive air pressure (CPAP) therapy provided via nasal prongs or mask has been identified by the neonatal skin care team at Duke University Medical Center as an area of particular concern. Infants cared for by this team may be very low birth weight (VLBW) — less than 1,500 g or 3.3 lb — or extremely low birth weight (ELBW) — less than 1,000 g or 2.2 lb.¹

    Continuous positive air pressure therapy was reported by Gregory² in 1971 to be an efficacious method of treatment for respiratory distress syndrome and is used today to wean infants from mechanical ventilators and to address apnea concerns. Early ventilator weaning can reduce the incidence of subglottic stenosis, tracheal stenosis, secondary infections, aspiration, and bronchopulmonary dysplasia (BPD).² In BPD, the delicate lung tissues may become injured when the alveoli are overstretched by mechanical ventilation or by high oxygen levels. After several years and the lung tissue heals, these children are at risk for developing asthma and viral pneumonia, such as that caused by respiratory syncytial virus (RSV).³

    Protecting the skin of the preterm infant is a challenge. In a review of the literature, Quinn et al⁴ reported that although the skin of the newborn infant is similar in function to an adult, the skin of the premature infant has poor barrier function. This can result in greater risk of injury and infection due to the thinness of the stratum corneum and the poorly developed dermoepidermal junction.

    Assessing and managing pain for hospitalized infants is an ongoing clinical challenge. According to a position statement issued by the National Association of Neonatal Nurses (NANN),⁵ clinical assessment of pain in the newborn is imprecise and a high index of suspicion is required to identify an infant in pain. Additional contributing factors to this challenge are related to the infant’s developmental maturity, behavioral state, clinical status, and environment. The Association encourages ongoing education regarding the assessment and management of pain in hospitalized infants for all healthcare professionals.⁵

The Problem

    Staff at the Duke University Medical Center Neonatal Intensive Care Nursery constantly strive to initiate nasal CPAP on low birth weight babies in the hopes of decreasing BPD and managing them off of mechanical ventilation. As soon as ventilator settings are low enough, the infant will be challenged to CPAP. Once CPAP is initiated for the ELBW/VLBW infant, the fragile tissue of the nares must be protected from pressure injuries and stripping that can occur at the base of the nasal septum (see Figure 1), on either side of the nares, and across the bridge of the nose. In addition to equipment placement around the nose, Duke clinicians have found increased infant activity, therapeutic handling, and frequency of and inconsistency with skin assessment to be factors in tissue damage.

    Of the various forms of CPAP and machine models, the author prefers the Aladdin/Infant Flow nasal CPAP system (Hamilton Medical, Reno, Nev) for its flexibility. Infants can be cared for on their sides or prone, making it somewhat easier to maintain good position. However, depending on the activity of the babies, clinicians have found them literally “hanging” from their noses (see Figure 2) whether using prongs or the mask; this results in significant pressure applied to the tip of the nose, the nasal septum, and surrounding tissue (see Figure 3). To try to minimize stripping, relieve pressure, stabilize the equipment, and reduce friction and shear, hydrocolloids and tape and gauze have been used as barriers and/or stabilizers. As a result of such practices, additional stripping and pain were evident. As noted in the literature,6 dressings and tapes with traditional adhesives remove the protective stratum corneum of many of the preterm infants in the author’s care. The complications of pressure ulceration and stripping have resulted, in extreme situations, in tissue loss that required postdischarge attention from the plastic surgery team.

The Solution

    Over the last year, clinicians at Duke have enhanced their practice and outcomes through identifying products that protect the epidermis of the infants they treat. Soft silicone dressings have been a part of that endeavor — they are easily removed and repositioned on the skin and provide an extra barrier for protection from the equipment. Additionally, clinicians may alternate between using the mask or prongs for delivery of therapy. Education regarding the techniques and practice is included in departmental competence labs for respiratory therapists, nurses, nurse practitioners and physicians.

    Under current protocol, when nasal CPAP therapy is initiated, silicone dressings are placed under the prongs or the mask to protect the fragile skin as a prophylactic measure (see Figure 4). Customized patterns are cut from Mepilex® Lite, (Mölnlycke Health Care, Norcross, Ga) to fit around the infants nose (see Figure 5) or across the upper lip (see Figures 6, 7) to address both types of CPAP delivery systems. The thinness and flexibility of the dressing provides conformability and security and does not interfere with the air delivery. Another significant benefit is that the edge of the soft silicone dressing can be lifted, allowing clinicians a quick observation of the area concerned with minimal disruption to the resting infant.

    With the new CPAP protocol instituted in the Duke IC Nursery, a significant reduction in tissue damage among the infant population has been noted. Education is ongoing, as proper applications and compliance to the regimen enhance outcomes. Infant comfort levels are recognized as pain scores utilizing the CRIES8 pain scale have decreased and overall irritability of the baby has lessened.

    Parent satisfaction with this new practice is evident — they see their baby’s comfort is addressed and that the nose and face are protected from injury. If a clinician has failed to place the dressing under the appliance, parents often will ask why. Since the skills labs were implemented and the new method of care accepted, staff members recognize the benefits and incorporate skin protection into their routine care. Application of the soft silicone protective barrier now is included in CPAP orders written by the physician and nurse practitioner team.

Conclusion

    Soft silicone dressings can protect fragile tissue and are identified as a dressing of choice for the reduction of the incidence of pain and discomfort associated with the dressing change procedure.⁷ With the new CPAP protocol instituted in the Duke IC Nursery, tissue damage among the infant population has been reduced. Education is ongoing; proper application and compliance to the regimen enhance outcomes. Infant comfort levels are evident as pain scale scores have decreased and overall irritability of the babies has lessened.

    Ongoing clinical concerns related to protection of these tiniest patients and clinical team creativity has led to the establishment of new best practice standards and improved patient outcomes.

    Addressing the Pain is made possible through the support of Mölnlycke Health Care, Norcross, Ga.

1. Tucker J, McGuire W. ABC of preterm birth: Epidemiology of preterm birth. Available at: http://www.studentbmj.com/issues/05/04/education/146.php. Accessed March 8, 2006.

2. Robertson NJ, McCarthy LS, Hamilton PA, Moss ALH. Nasal deformities resulting from flow driver continuous positive air pressure. Arch Dis Childhood, Fetal and Neonatal Edition. 1996;75(3):209F–212F.

3. Bronchopulmonary dysplasia. Available at: http://www.merck.com/mmhe/au/sec23/ch264/ch264l.html. Accessed March 8, 2006.

4. Quinn D, Newton N, Pieuch R. Effect of less frequent bathing on premature infant skin. JOGNN. 2005;34(6):741–746.

5. National Association of Neonatal Nurses. Position Statement #3019, Pain Management in Infants. 1999. Available at: http://www.nann.org/files/public/3019.doc. Accessed March 8, 2006.

6. Dykes PJ, Heggie R, Hill SA. Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care. 2001;10(2):7–10.

7. Moffatt C. Pain at wound dressing changes: a guide to management. European Wound Management Association Position Document. London, UK: Medical Education Partnership LTD;2002.