Introduction

The skin is the largest human organ and performs several functions. The three layers that make up the skin organ, known as epidermis, dermis and hypodermis, are attached to and supported by the subcutaneous tissue. The epidermis, the outermost layer, consists of the stratum corneum responsible for preventing loss of fluids and protecting against the invasion of harmful agents, as its function is of a barrier and protective agent for the skin, as well as preventing transepidermal loss of fluids. ^(1,2

In turn, the dermis is made up of collagen and elastin fibers that provide support, elasticity and resistance to the skin. ⁽¹ These characteristics can vary according to each person’s age since, when compared to adult skin, the dermis of Newborns (NBs) has fewer elastic fibers. In addition to that, NBs have a more immature and deficient dermoepidermal junction, in addition to greater permeability related to their greater body surface in comparison to their weight. For these reasons, they are at a higher risk of developing injuries and absorbing chemical agents, as well as a greater percutaneous reaction to irritating substances. ³

NBs’ skin requires careful and continuous evaluation because, in addition to representing the body surface, it is one of the criteria for evaluating their maturity according to gestational age and skin appearance. Thus, premature infants have thin and gelatinous skin whereas full-term ones have smoother skin, with a shiny and moist appearance. Finally, post-term neonates may have dry, wrinkled skin with apparent peeling. For physiological purposes, the skin has a direct relationship with thermoregulation and guarantees vitality at birth. ¹

It is important to maintain newborns’ skin integrity since, in addition to essential thermoregulation for extrauterine adaptation, it also acts as a protective barrier for the body. Preserving its natural protective functions can prevent the emergence of infections caused by disruption of the epithelial tissue. In this context, nurses develop fundamental actions in the prevention and treatment of wounds; considering that these professionals work directly in the assessment of skin integrity, as well as in the care and dressing of wounds in newborns, mainly in the hospital setting. ²

Some studies point to the incidence and prevalence of wounds in the neonatal population, with emphasis on those that affect newborns when hospitalized: wounds resulting from congenital malformations; ³ dermatitis associated with diaper use; ² drug infiltrations and extravasations; traumatic injuries evidenced by hematomas, erythemas, abrasions and ecchymosis; oximeter burns; and pressure injuries related to clinical devices in Intensive Care Units (ICUs). Most of these harms can be prevented, oftentimes resulting from unplanned care. ^2,3,4

Although various studies address preventive measures for the emergence of wounds in the neonatal population, ^1,2,3) there is no standardized consensus for treating them. The existing data are still limited for newborns; therapeutic approaches are based on evidence for adults, which makes wound treatment difficult and/or compromised in such a specific population group, in addition to scarce guidelines for neonatal skin care, which limits adherence to best management practices for neonatal skin ruptures. ⁵

The literature describes some efficient dressings for treating wounds in newborns, but with weaknesses considering that the vast majority of these products were developed for use in the adult population, making it necessary to pay attention to patient safety as a guiding principle in Neonatology care, taking as first ground the objective of not causing harm.^3,6,7) Furthermore, there is also no standard for comparing the benefits of different types of dressings in relation to each other, in addition to the associated pain levels, clinical assessment, or presence of infection required for treatment planning. Finally, the gaps in the literature point to the need to carry out more prospective studies that seek to evaluate safety of these products in Neonatology. ⁵

Thus, this study aims at identifying in the literature the main dressings and products used for the treatment of wounds in newborns.

Methodology

Inclusion criterio

As inclusion criteria, original articles, case reports and update articles were adopted, which had full texts and were available for analysis, in any language, published from 2018 to 2023 and directly related to the study object. Clinical guides and protocols were excluded, as well as literature reviews and duplicate studies.

The data extraction process was systematized with the support of a previously prepared instrument, organized by internal and external indicators: author, title, year of publication, journal, objective, type of study and main findings. Thus, search and selection of the manuscripts was carried out through pair search, applying the PRISMA guideline. ¹⁰ At the end of this search, 110 articles were identified, of which 4 were excluded for being duplicates and 70 for not meeting the study inclusion criteria.

Initially, 36 publications were selected and subjected to a thorough reading process, of which 15 were discarded because they were not associated with the theme, with 21 remaining for the eligibility assessment. In the end, 08 articles were excluded for not responding to the objective proposed in this research, resulting in 13 manuscripts to comprise the synthesis of this review, according to the PRISMA flowchart ¹⁰ (Figure 1).

Figure 1: Flowchart corresponding to the search and selection of studies in indexed databases adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020), 2023, Bahia, Brazil 

Results

The sample was made up of 13 international articles and only one Brazilian publication on the topic. Depending on where the studies were carried out, four took place in the USA, two no Iran, one in Argentina, one in Turkey, one in Israel, one in Russia, one in Italy, one in Germany and one in Brazil. The review included four case reports, three clinical trials, two case-control intervention studies, three cross-sectional observational studies and one cohort study. The publications ranged from 2018 to 2022. Table 1 2,3 presents data from each study and the variables analyzed.

Table 1: Summary of the articles selected structured by title, authors, country, year, objectives, type of study and main results. Salvador, Bahia, Brazil, 2023 

The articles included in this review evidenced the most common wounds that affect the neonatal population. Therefore, the total was 14 types of wounds reported in the studies, of which five studies referred to the treatment of complex congenital wounds, four to surgical wounds, three to burns, one study pointed to the treatment of injuries due to leaks and infiltration and one to device-related pressure injury. Figure 2 below stratifies the main complex injuries evaluated for treatments in newborns.

Figure 2: Main types of complex wounds that affect newborns according to the number of studies published in the 2018-2023 period, Bahia, Brazil, 2023. 

The research made it possible to list 16 types of products or dressings associated or not with Negative Pressure Therapy (NPT), also cited as vacuum, used for the treatment of injuries in newborns. Table 2 describes the types of dressings and their classification according to the model proposed by Fan et al., ¹¹ in addition to presenting the number of studies that reported their use and the types of wounds treated in the neonatal population.

Table 2: Types of dressings and products used in the treatment of neonatal wounds structured according to the model proposed by Fan et al., 2011. ¹¹ Bahia, Brazil, 2023 

Discussion

Although the literature presents many publications on the treatment of wounds in the adult population, few studies were found involving the same theme in the Neonatology field, mainly in the area related to the safe use of dressings. Knowing the anatomy and physiology of newborns’ skin becomes an important aspect for planning safe and individualized care. Due to the peculiarities and sensitivities of this organ in newborns, the risks for percutaneous absorption of substances, infections and wounds are increased. Skin injuries expose newborns to infectious agents, which can not only cause death but also irreversible sequelae and scars. In this context, constant skin evaluation by nurses and/or a multiprofessional team becomes necessary to prevent and treat complex wounds in this population segment. ^1,14

A study demonstrates the relevance of nurses’ work in the care ⁽²⁸⁾, prevention and maintenance of newborns’ skin integrity. ^1,2,3 However, the evolution of the care process, the dynamics and changes in habits and customs driven by the growing technological development in health have proposed gains in the treatment of wounds, mainly in the work of surgeons. ^{13,16,17,18,19,20,21,22,23} Therefore, the therapeutic process of this problem in newborns is still a challenge for the professionals who work in this context, which indicates both technical and educational investments.

The wounds that affect NBs can be congenital ^22,23) and most of them result from the hospitalization process and/or neglected care, evidenced by pressure injuries, ⁷ dermatitis associated with diaper use, ^2,4,5 infiltration and chemical leaks, ^13,19 exposure to medical devices, ⁷ multiple invasive procedures and even surgical procedures to correct conditions.^{12,16,18,20,21,22}

Thus, it becomes indispensable to invest in the in-hospital care process to minimize harms and risks to newborns, in addition to expanding knowledge on curative practices that accelerate the wound healing process in the neonatal population, contributing to reducing the hospitalization times and, consequently, the hospital costs. ^24,25

Hospitalization units focused on neonatal patients leave them more vulnerable to errors. ^19,25,26,27 Wounds caused by leaks of solutions or drugs can be frequent, mainly when dealing with neonates with a severe clinical profile that requires the use of vesicant and irritating drugs, in addition to parenteral nutrition.^20,21,22

For this type of wound, the literature indicates using the vacuum grafting and healing method. ¹³ The use of Dermal Regeneration Template techniques, ¹⁹ in addition to carboxymethylcellulose hydrofiber dressing with ionized silver (AgCMCH), polyethylene-polyethylene terephthalate hydrofiber dressing with elemental silver (Ag-PPAF), calcium alginate (CA), calcium alginate + zinc (CAZ) and gauze with 0.2 % nitrofurazone (NF) were compared and proved to be effective, despite highlighting that dressings containing silver should not be considered as the gold standard for noninfectious partial burns in children. ¹⁵ Even so, all of them showed satisfactory wound healing responses, reducing necrotic tissue and increasing granulation tissue growth.

Hydrocolloid was indicated to prevent injuries caused by the use of a nasal oxygen therapy device. ¹² However, it is known to have diverse uses in adult wounds; this material is recommended both as a preventive measure and as a dressing applied to the site. It is a carbohydrate polymer that both protects the wound and controls its exudation. Occlusion accelerates epithelialization, preserves the acute wound fluid under the occlusive bandage that contains substances, such as growth factors, stimulating the proliferation of fibroblasts and endothelial cells, promoting the formation of granulation tissue. ³¹

Another aggravating factor that affects newborns with wounds is exposure to infectious agents that can colonize the wound site, compromising the healing process and increasing the risk of a generalized infection capable of leading to death and, therefore, they should be strictly monitored. In this context, although little used in the Neonatology area, silver was instituted, even in premature newborns that had first-degree burns. ^25,26 Silver is an excellent antimicrobial agent; however, this active ingredient can be systematically absorbed and cause hyponatremia and hypokalemia, in addition to nitrate being converted into nitrite with oxidizing power capable of damaging the cell. ^27,28

In view of the above, the use of silver should be carefully indicated with possible monitoring and serum control. In the case of neonates, who commonly present hydroelectrolyte changes when seriously ill, there is an urgent need for professionals to monitor the electrolyte levels when this type of therapy is instituted, as well as strict control of any exchanges.

Another product recommended for the neonatal population with infectious wounds is calcium alginate. Although widely used in Neonatology, it should not be employed randomly and without adequate monitoring, as it releases sodium and calcium into the lesion bed, which can be absorbed systemically. ²⁹ However, this passive dressing can accelerate debridement and maintain a physiologically moist microenvironment which allows gas exchange; in addition, it controls exudate and minimizes colonization by microorganisms, promoting healing and the formation of granulation tissue, requiring successive evaluations by the Nursing team. ^30,31

According to a study carried out in Turkey, active products were used in the presentation of ointments, gels and solutions to treat injuries in this population group. Calcium Alginate (CA) and Calcium Alginate + Zinc (CAZ) ¹⁵ are cited, respectively, with important healing results such as stimulation of granulation tissue growth, maintenance of moisture and favoring exchanges, and debriding actions, as well as antibacterial activity in the treatment of burns.

Although incipient, the search for new products to treat wounds in newborns has been gaining prominence. Studies developed in Iran ⁽¹² and the United States ²³⁾ employed Leptospermum Honey, a type of honey with anti-inflammatory and antibacterial properties, effective even when used on multi-resistant bacteria such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, in addition to promoting wound debridement. ^{12,23,24,28,30}

In addition to being used in treatments, the dressings applied in the care of neonatal wounds stand out for their preventive action, mainly with regard to pressure injuries and friction caused by medical devices. ^7,31 The market already offers a variety of carboxymethylcellulose hydrofiber dressings with ionized silver (AgCMCH), as well as polyethylene-polyethylene terephthalate hydrofiber dressings with elemental silver (Ag-PPAF), in addition to paraffin gauze and gauze with 0.2 % nitrofurazone (NF), cited in studies that use these resources in the therapeutic processes of burns ^15,30,31 in the neonatal population. ²⁹ Thus, foams and silicones act to control exudates, accelerate the epithelialization process through the occlusive system and can avoid routine dressing exchanges.

Some studies report that extensive wounds in neonates require innovative treatments such as the use of Dermal Regeneration Template (DRT) associated or not with Negative Pressure Therapy ¹⁹ and collagen dermal template. ¹⁴ These products consist of a piece of collagen-based tissue and were indicated for the treatment of premature newborns who suffered leaks and had a slow healing course, reducing inflammatory responses and promoting tissue growth and regeneration. DRT associated with NPT offers a higher success rate in the treatment of complex wounds caused by burns, promotes an increase in the DRT taking rate, reduces the DRT maturation time and increases the skin graft taking rate. A number of research studies conclude that skin allografts ⁵ are used in the treatment of large skin defects for temporary wound dressing, minimizing water, electrolyte, heat and protein losses and as a physical barrier against infections. ²⁷

There is a strong association between dressings and products and other therapeutic modalities in the treatment of injuries, such as Negative Pressure Therapy (NPT). ^19,25,26 Thus, several denominations and nomenclatures are used to highlight the use of this treatment, such as: CAV (cicatrización asistida por vacío); ¹³ Vacuum Closure (VC); ^17,18 Negative Pressure Closure;²¹ Vacuum-Assisted Closure; ¹⁶ Negative Pressure; ²⁵ and Negative Pressure Therapy (NPT). ^19,20,22,23

These research studies indicate that NPT not only reduces biofilm formation in the wound bed but also accelerates the granulation tissue growth process, favoring wound closure. Diverse evidence shows that this therapy reduces edema and vascular permeability, in addition to increasing angiogenesis and blood flow to the wound borders. ^19,25,26

In turn, the use of Hyperbaric Oxygen Therapy (HBOT) was found in a study ²² for the treatment of complicated sternal wound infections after pediatric cardiac surgery refractory to antibiotic therapy and/or debridement, which can be successfully treated with NPT and/or HBOT. The most common bacterium isolated from blood or wound cultures was Staphylococcus aureus.

Although not reported in the studies included in the review, physiological serum (0.9 %) is widely used in wound care because it has important properties that do not alter the healing process, do not damage tissues, and do not cause sensitivity reactions or allergies, in addition to not altering the normal bacterial flora of the skin. ^28,29,30 Therefore, in the case of neonates, crystalloid solutions are more indicated.

Finally, it is worth noting the need for a thoughtful analysis of the conditions of neonatal patients, as well as the characteristics of the injuries that require treatment. ^4,6,28 Thus, it is possible to establish a care plan that involves everything from adapting the most suitable dressing to implementing actions that guarantee safety in the treatment of wounds, as it is necessary to have products for health services suitable for Neonatology, without improvisations for skin hygiene, catheter fixation and hand hygiene products, ^7,28,29,30 among other procedures that can prevent and treat wounds in Neonatology.

Final considerations

The study concludes that discussions about wound treatment practices in newborns are still incipient when compared to treatments aimed at the adult population. Different dressings and products contribute to satisfactory healing processes in newborns, including premature ones. Advances in the area already point to the use of innovative therapeutic modalities, resorting to different types of dressings for NBs.

Therefore, as a result of the incipient discussion regarding the safety of neonatal patients when treating wounds, it is worth noting the gap identified and its importance in considering the prevention of errors that result in injuries, as well as the safe use of adequate dressings for newborns in view of the composition of the products, in addition to the need for specific care measures such as serum monitoring of substances that might cause poisoning in this population segment.