Skin barrier in the neonate

Invasive Candida Infections in Neonatal Intensive Care Units: Risk Factors and New Insights in Prevention

Invasive Candida infections represent a significant cause of morbidity and mortality in neonatal intensive care units (NICUs), with a particular impact on preterm and low-birth-weight neonates. In addition to prematurity, several predisposing factors for Candida colonization and dissemination during NICU hospitalization have been identified, including prolonged exposure to broad-spectrum antibiotics, central venous catheters, parenteral nutrition, corticosteroids, H2 antagonist administration, and poor adherence to infection control measures. According to the literature, the implementation of antifungal prophylaxis, mainly fluconazole, in high-risk populations has proven to be an effective strategy in reducing the incidence of fungal infections. This review aims to provide an overview of risk factors for invasive Candida infections and current perspectives regarding antifungal prophylaxis use. Recognizing and reducing people's exposure to these modifiable risk factors, in conjunction with the administration of antifungal prophylaxis, has been demonstrated to be an effective method for preventing invasive candidiasis in susceptible neonatal populations.

Applying Vernix Caseosa for Accidental Foetal Lacerations during Caesarean Delivery: A Case Series

The caesarean section is a frequently performed method of delivery. Although the caesarean section is a low-risk and safe surgery, there is an increase in maternal and infant morbidity and mortality due to caesarean delivery. One of the most common infant morbidities is foetal laceration. Caesarean delivery has a 1-2% risk of laceration to the foetus. Various methods have been proposed to deal with laceration wounds. Studies have been conducted on vernix caseosa, which can heal wounds on the skin. This case series report aims to demonstrate that vernix caseosa application is a wound healing method that is highly effective, costless, and of immediate availability.

Human Breast Milk: The Key Role in the Maturation of Immune, Gastrointestinal and Central Nervous Systems: A Narrative Review

Premature birth is a major cause of mortality and morbidity in the pediatric population. Because their immune, gastrointestinal and nervous systems are not fully developed, preterm infants (<37 weeks of gestation) and especially very preterm infants (VPIs, <32 weeks of gestation) are more prone to infectious diseases, tissue damage and future neurodevelopmental impairment. The aim of this narrative review is to report the immaturity of VPI systems and examine the role of Human Breast Milk (HBM) in their development and protection against infectious diseases, inflammation and tissue damage. For this purpose, we searched and synthesized the data from the existing literature published in the English language. Studies revealed the significance of HBM and indicate HBM as the best dietary choice for VPIs.

The Fate of Epidermal Tight Junctions in the stratum corneum: Their Involvement in the Regulation of Desquamation and Phenotypic Expression of Certain Skin Conditions

We evaluated the presence of tight junction (TJ) remnants in the stratum corneum (SC) of in vitro reconstructed human epidermis and human skin explants subjected or not to an aggressive topical treatment with beta-lipohydroxy salicylic acid (LSA) for 24 h. LSA-treated samples showed an increased presence of TJ remnants in the two lowermost layers of the SC, as quantified with standard electron microscopy. The topical aggression-induced overexpression of TJ-like cell–cell envelope fusions may influence SC functions: (1) directly, through an enhanced cohesion, and (2) indirectly, by impeding accessibility of peripheral corneodesmosomes to extracellular hydrolytic enzymes and, thus, slowing down desquamation. Observations of ichthyotic epidermis in peeling skin disease (PSD; corneodesmosin deficiency; two cases) and ichthyosis hypotrichosis sclerosing cholangitis syndrome (IHSC/NISCH; absence of claudin-1; two cases) also demonstrated increased persistence of TJ-like intercellular fusions in pathological SC and contributed to the interpretation of the diseases’ pathological mechanisms.

Infection prevention for extremely low birth weight infants in the NICU

Extremely preterm infants are particularly vulnerable to systemic infections secondary to their immature immune defenses, prolonged hospitalizations, delays in enteral feeding, early antibiotic exposure, and need for life-sustaining invasive interventions. There have been several evidence-based practices for infection prevention in this population, such as human milk feedings, utilization of "bundle checklists" and decolonization of pathogenic organisms. Other practices, such as the use of probiotics, human milk-derived fortifiers, and antifungal prophylaxis are more controversial and require further investigation regarding the risks and benefits of such interventions. This chapter examines the susceptibility of the preterm newborn infant to invasive infections and describes several strategies for infection prevention, along with the associated limitations of such practices. It also addresses the various gaps in our understanding of preventing infections in this population, and the need for additional large multi-center randomized controlled trials. Additionally, the role of the SARs-CoV-2 global pandemic and associated strategies for infection prevention in the NICU are discussed.

Fluid Homeostasis and Diuretic Therapy in the Neonate

Understanding physiologic water balance and homeostasis mechanisms in the neonate is critical for clinicians in the NICU as pathologic fluid accumulation increases the risk for morbidity and mortality. In addition, once this process occurs, treatment is limited. In this review, we will cover fluid homeostasis in the neonate, explain the implications of prematurity on this process, discuss the complexity of fluid accumulation and the development of fluid overload, identify mitigation strategies, and review treatment options.

Epigenetic Modification of PD-1/PD-L1-Mediated Cancer Immunotherapy against Melanoma

Malignant melanoma is one of the representative skin cancers with unfavorable clinical behavior. Immunotherapy is currently used for the treatment, and it dramatically improves clinical outcomes in patients with advanced malignant melanoma. On the other hand, not all these patients can obtain therapeutic efficacy. To overcome this limitation of current immunotherapy, epigenetic modification is a highlighted issue for clinicians. Epigenetic modification is involved in various physiological and pathological conditions in the skin. Recent studies identified that skin cancer, especially malignant melanoma, has advantages in tumor development, indicating that epigenetic manipulation for regulation of gene expression in the tumor can be expected to result in additional therapeutic efficacy during immunotherapy. In this review, we focus on the detailed molecular mechanism of epigenetic modification in immunotherapy, especially anti-PD-1/PD-L1 antibody treatment for malignant melanoma.

Neonatal invasive candidiasis: updates on clinical management and prevention

Neonatal invasive candidiasis is an important cause of morbidity and mortality in preterm infants. The incidence of invasive candidiasis in this population has been declining in high-income settings, largely due to preventive measures, although there are still considerable variations in incidence between health-care centres. Surveillance data and large, multicentre studies in lower-income settings are not available, although preventive measures in these settings have been shown to decrease the incidence of neonatal invasive candidiasis. Understanding risk factors and pathogenesis are key to the prevention of invasive candidiasis. The difficulty of a definitive diagnosis of invasive candidiasis and the high risk for death or substantial neurodevelopmental impairment, even with appropriate treatment, further increase the need for effective preventive measures. In this Review, we examine the pathogenesis, clinical presentation, and diagnosis of invasive candidiasis. We highlight commonly used and emerging preventive and prophylactic measures, including standardised central line care, antibiotic stewardship, antifungal prophylaxis, and probiotics. Finally, we provide updates on empirical treatment, clinical management in confirmed cases of invasive candidiasis, and antifungal pharmacotherapy.

Newborn-oriented and environmental factors for newborns' skin barrier functions

AIM

This study aimed to examine newborn-oriented and environmental factors of newborn skin barrier functions.

METHODS

This was a retrospective secondary analysis of 227 newborns from a previous study. Newborn skin barrier functions were measured on the fourth day after birth via the following parameters: stratum corneum hydration, transepidermal water loss, skin pH, and sebum secretion. Skin barrier functions were measured at four body sites; their averaged values were used for the analysis. The associations among skin barrier functions, newborn-oriented factors, and environmental factors were evaluated. Multiple regression analysis was performed using a forced entry method, and independent variables for which p-values were <.05 in Student's t test, analysis of variance, and Pearson's correlation analysis were included.

RESULTS

A total of 211 participants were analyzed. The mean ± standard deviation values of stratum corneum hydration, transepidermal water loss, skin pH, and sebum secretion were 28.58 ± 8.40 and 7.28 ± 2.02 g/m² /h, 5.77 ± 0.53, and 23.59 ± 15.89 μg/cm² , respectively. Newborn-oriented factors (gestational days, weight, amount of vernix, and parity) and environmental factors (birth season) were significantly associated with one or more skin barrier functions.

CONCLUSIONS

Newborn-oriented (including labor- and delivery-related) and environmental factors were associated with the skin barrier functions. The newborn maturity level, newborn sex, environmental temperature, and humidity may affect skin barrier functions in newborns. Further studies should focus on the effects of these factors on newborn skin barrier assessments, and develop tailored skincare strategies based on their characteristics.

Plasma Leak From the Circulation Contributes to Poor Outcomes for Preterm Infants: A Working Hypothesis

Preterm infants are at high risk of death and disability resulting from brain injury. Impaired cardiovascular function leading to poor cerebral oxygenation is a significant contributor to these adverse outcomes, but current therapeutic approaches have failed to improve outcome. We have re-examined existing evidence regarding hypovolemia and have concluded that in the preterm infant loss of plasma from the circulation results in hypovolemia; and that this is a significant driver of cardiovascular instability and thus poor cerebral oxygenation. High capillary permeability, altered hydrostatic and oncotic pressure gradients, and reduced lymphatic return all combine to increase net loss of plasma from the circulation at the capillary. Evidence is presented that early hypovolemia occurs in preterm infants, and that capillary permeability and pressure gradients all change in a way that promotes rapid plasma loss at the capillary. Impaired lymph flow, inflammation and some current treatment strategies may further exacerbate this plasma loss. A framework for testing this hypothesis is presented. Understanding these mechanisms opens the way to novel treatment strategies to support cardiovascular function and cerebral oxygenation, to replace current therapies, which have been shown not to change outcomes.

Development of a Nursing Guideline for Improving Skin Integrity in High-Risk Infants

BACKGROUND

High-risk infants are highly susceptible to skin impairment caused by invasive procedures, radiant warmers, and phototherapy, in addition to their intrinsic vulnerability. This leads to a vicious cycle that aggravates the risk of skin infections. Concerns have been raised that neonatal nurses may lack knowledge regarding feasible guidelines to improve skin integrity of high-risk newborns.

METHOD

A clinical guideline was developed for neonatal skin care practices based on skin physiology, and its educational effects on the knowledge and confidence of neonatal nurses was evaluated. A booklet was developed on skin care practice guidelines divided into topics determined through a nationwide survey.

RESULTS

Using a quasi-experimental design with 46 neonatal nurses, education with this booklet improved nurses' knowledge of skin care practices but not their confidence.

CONCLUSION

These findings highlight the importance of implementing a tailored systematic program rather than a single educational session on skin care in high-risk infants for neonatal nurses. [J Contin Educ Nurs. 2020;51(5):238-244.].

Biology of the vernix caseosa: A review

The vernix caseosa is a complex membranous structure comprising 80% water, 10% protein, and 10% lipids including barrier lipids such as ceramides, free fatty acids, phospholipids and cholesterol, synthesized partly by fetal sebaceous glands during the last trimester of pregnancy in an antero-posterior and dorsoventral manner. Because of its lipid content, vernix is hydrophobic and protects the skin from excessive water exposure during the development of the stratum corneum. The vernix caseosa has various functions during fetal transition from an intrauterine to an extrauterine environment, including lubrication of the birth canal during parturition, barrier function to prevent water loss, temperature regulation, for innate immunity and for intestinal development. This review discusses the evidence supporting the prenatal and postnatal functions of vernix caseosa, along with its structure, composition, and physical and biological characteristics. Understanding the biology of the vernix may facilitate improved care of preterm infants immediately post-partum.