What are the recommended skin care practices for a 23-week gestation infant?

Skin Care for a 23-Week Gestation Infant

For a 23-week gestation infant, immediately place the unwrapped, undried infant in a plastic bag or wrap up to the neck, add a head covering, and maintain delivery room temperature at ≥23°C (ideally 23-25°C) under a radiant warmer to prevent life-threatening hypothermia, which is the single most critical skin-related intervention at this gestational age. 1

Immediate Thermal Protection (First Priority)

The most critical aspect of skin care for a 23-week gestation infant is preventing hypothermia through the immature skin barrier:

• Do not dry the infant before applying thermal interventions – place the infant directly into a clean food-grade plastic bag or wrap without drying, covering the body up to the neck but leaving the face exposed 1, 2
• Apply a head covering (cap) immediately, as significant heat loss occurs through the large surface area of the head 1
• Maintain delivery room ambient temperature at ≥23°C, with 23-25°C being optimal 1
• Use a radiant warmer in the delivery room and during stabilization 1, 2

This combination approach has high-certainty evidence showing improved survival (NNT=24) and reduced hypothermia (NNT=3) in preterm infants <34 weeks gestation. 1, 2

Critical Pitfall to Avoid

Never dry a 23-week infant before plastic wrapping, as this defeats the purpose of reducing evaporative heat loss through the extremely permeable skin barrier. 2 The traditional practice of drying applies only to term infants. 3

Ongoing Skin Barrier Protection

Once stabilized in the NICU, focus shifts to maintaining skin integrity:

Bathing and Cleansing

• Limit bathing to 2-3 times per week maximum using water alone or with minimal non-alkaline, pH-neutral cleanser 1, 4, 5
• Avoid soap and traditional cleansers entirely during the neonatal period for extremely preterm infants 6
• When cleansing is necessary (e.g., diaper area), use only products specifically designed for neonatal skin with neutral pH 4, 5
• Baby wipes with emollient cleansers are superior to cloth and water for maintaining skin barrier function, showing significantly lower erythema and transepidermal water loss (TEWL) by day 5-7 7

Emollient Application

• Apply bland, thick emollients (creams or ointments) 3-8 times daily to decrease TEWL 1
• Use sterile occlusive ointments such as white petrolatum, though water-in-oil emollients are an alternative if infection risk is a concern 1
• Products containing ceramides help maintain the protective skin barrier and support the maturation process 5, 8
• Avoid emollients containing active substances like urea, salicylic acid, or silver sulfadiazine due to risk of percutaneous absorption and toxicity 1
• Use single-use packets and latex-free gloves during application to avoid contamination 1

Skin Fragility Management

• Handle the infant with extreme gentleness, as the skin at 23 weeks is highly fragile and prone to ulcerations, erosions, and bleeding with minimal trauma 1
• Use non-adherent dressings if skin breakdown occurs 1
• Monitor for signs of skin injury during routine care and medical procedures 1

Temperature Monitoring and Hyperthermia Prevention

Continuous temperature monitoring is essential to prevent iatrogenic hyperthermia, which increases mortality, seizures, and neurologic injury: 2, 9

• Monitor axillary temperature every 15-30 minutes until stable normothermia (36.5-37.5°C) is achieved 2, 9
• Avoid hyperthermia (>38.0°C) at all costs – this is as dangerous as hypothermia 1, 2
• Do not use thermal mattresses in combination with plastic wrap, as this combination increases hyperthermia risk 3.67-fold 2
• Stop active warming when core temperature reaches 36.5°C 2

Infection Prevention

Extremely preterm skin has impaired barrier function, increasing infection risk:

• Perform regular bacterial swabs (twice weekly) from flexures, eyes, and IV sites 1
• Use aqueous chlorhexidine 0.05% on erosive lesions 1
• Apply antifungal creams to macerated skin areas to prevent fungal colonization 1
• Do not use prophylactic antibiotics routinely, but maintain vigilance for signs of infection 1
• Change dressings using aseptic technique 1

Respiratory Support Considerations

If the infant requires respiratory support (highly likely at 23 weeks):

• Use heated and humidified gases when available, as this reduces moderate hypothermia (NNT=14) and may reduce severe intraventricular hemorrhage 1
• This intervention provides additional protection against heat and water loss through the respiratory tract 1

Environmental Humidity

While not explicitly addressed in the highest-quality guidelines for 23-week infants, maintaining appropriate environmental humidity in the incubator helps reduce TEWL through the immature skin barrier. 1 This should be coordinated with neonatology protocols for extremely preterm infants.

Common Pitfalls Summary

• Never delay thermal protection to perform other assessments – hypothermia develops within minutes 2
• Never dry the infant before plastic wrapping 2
• Never use multiple warming devices simultaneously without continuous monitoring (hyperthermia risk) 2
• Never apply products with active ingredients that can be absorbed (urea, salicylic acid) 1
• Never use alkaline soaps or traditional cleansers 4, 5