Documento sem título

RESEARCH ARTICLES

 

Skin lesion in newborns and infants

 

Albaneide dos Santos FerreiraI; Ana Letícia Cabral InteraminenseGuerraII; Marly JavorskiIII; Suely de Fátima Santos Freire BonfimIV; Thaís de Almeida da SilvaV; Luciana Pedrosa LealVI
IRN, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: : binnha84@yahoo.com.br
IIRN, Federal University of Pernambuco. Recife, Pernambuco, Brazil. E-mail: aninha_guerra_@hotmail.com
IIIRN, PhD Student at Interinstitutional Doctoral Program of Federal University of Ceará and Federal University of Pernambuco. Professor at Nursing Department, Health Sciences Centre, Federal University of Pernambuco, Brazil. E-mail: marly_11j@gmail.com
IVRN, Master in Nursing Science, Head of Neonatal Unit, University Hospital of Federal University of Pernambuco, Brazil. E-mail: sfbonfim@uol.com.br
VRN, Master Student at Graduate Program of Federal University of Pernambuco, Brazil. E-mail: thaisas84@gmail.com
VIRN, PhD. Professor at Nursing Department, Health Sciences Centre, Federal University of Pernambuco, Brazil. E-mail: lucianapleal@hotmail.com ; ppgenfermagem.ufpe@gmail.com      


ABSTRACT: Cross-sectional, descriptive, quantitative study, aiming to analyze the factors associated with skin lesions in newborns and infants treated at the pediatric outpatient clinic of a university hospital in Recife-PE, Brazil. It was performed by interviews with 105 mothers and skin inspection of children between June and August 2011. Data were analyzed using EpiInfo software, version 6.04. The factors associated with skin lesions were investigated with chi-square and Fisher tests. The lesions occurred in 81 (77.1%) children. It was found that 38 (46.9%) showed a papule and 50 (61.7%) lesions were in the head. Over 83% of children who used shampoo or conditioner and softener hygiene and/or washing powder for washing clothes had lesions. Skin problems presented high prevalence in this population, suggesting the need for nursing actions concerning orientation for skin care.

Keywords: Wounds and injuries; newborn; infant; pediatric nursing.


 

INTRODUCTION

 

Newborn skin is a continuous, thin, delicate, sensitive and fragile surface1-3. Even thoughit has a structure similar to an adult’s skin, it has many immature functions4, more sensitivity to irritant chemicals and porosity to toxic agents, being subject to the appearance of lesions as an answer to minimal traumas5.

Susceptibility to lesions demands from nursing teams attention to mothers’ care, orientating them to avoid newborns skin lesions6.

In this sense, child care nursing consultation becomes ideal scenery to educative action, in which a relevant role is performed to the proper development of a child, focused on damage prevention, health promotion and prevention.

So, nurse professionals, especially nurses that perform child care consultation as basic attention, shall be familiar to characteristics and factors determinant to skin lesions and its relations to care dispensed to children, in order to subsidize education actions’ planning.This study aimed at analyzing associated causes to newborn and breast-fed skin lesions.

LITERATURE REVIEW

Products destinedto hygiene and skin protection of newborns and infants demand more care in its formulation, due to characteristics of skin of this age group. The elimination of substances potentially toxic and damaging to the skin is fundamental in the formulation of these products1,7.

Skin barrier frailty in newborns imposes skin care that can minimize morbimortality associated to this problem in the neonatal period. So, it is important to bear in mind the particularities of child skin to prevent risks associated to the use of skin products1,4,5.

It is worth mentioning the importance of orientation related to newborn and breast-fed care, offered to mothers and/or caregivers by nurses.Notwithstanding, effective actions in this situation require the knowledge of the commonest lesions in this age group and its relation to mother care destined to children8.

METHODOLOGY

Descriptive, transversal and quantitative study, performed in Childcare Ambulatory of the Clinic Hospital of Federal University of Pernambuco, in the city of Recife/PE.

Population was composed of newborns in their first consultation after hospital leave and breast-fed in their first nurse consultation in childcare. Nonprobabilistic and unintentional sampling9 had 105 children less than two months old attended between June and August of 2011.

Data collection was done through structured interviews and physical examination destined to newborn and breast-fed skin inspection.

Pilot test was performed to adequacy of the instrument and operationalization of data collection. As there were no relevant changes in the instrument, those five children of the pilot test were included in the sampling. Data collection form was structured in six parts related to newborn or breast-fed identification, mothers’ social data, prenatal assistance, housing conditions, skin lesions and mother care to newborn/breast-fed.
As dependent variable it was defined the presence of skin lesions. To the identification of newborn or breast-fed, it was characterized the age expressed in days (0 to 28 – newborn, 29 to 60 – breast-fed), gestational age (premature, full term and post-term newborns) information provided in hospital leave records, sex and type of consultation (consultation for hospital leave patients or childcare consultation).

To maternal identification, it was analyzed age (≤ 20 and> 20 years), civil status (married, single, stable union, divorced or widow), maternal formal education (< 8 and ≥ 8 years of study), umber of children, number of prenatal consultations (< 6 and ≥ 6 consultations), prenatal orientations and offered instructions (oral hygiene, intimate hygiene, bath, products used in hygiene, general care, sunbathing and others).

In reference to housing conditions, dwellings were characterized (owned, rented ou provided by someone else without monetary compensation), type of dwelling (masonry, pug, timber), waste treatment (collected, burned, deposited in wasteland), existence of piped water and sanitation.

As for body hygiene, characterization was done by the number of daily baths, bath technique (correct or incorrect), type and number of products used (shampoo, conditioner, child soap, bar soap), use of perfume and child fingernail cutting.

Relating to care with genital area, it was characterized the sort of diapers used (disposable and cotton), use and frequency of cream or ointments, products used for hygiene (baby wipes, cotton and lukewarm water, wipes, cotton and lukewarm water), genital area hygiene techniques (correct or incorrect), change of diapers at each episode of fecal or urinary elimination.

It was also characterized the products used to wash children clothing (powder soap and softening, only powder soap, bar soap, coconut bar soap and softening, only coconut bar soap), presence of insects in the dwelling, use of mosquito nettings, insect repellent or skin ointment.

Childcare support was characterized as having it or not and who supported (father, brother, sister, grandmother, grandfather, uncle, aunt, professional caregiver and others). Maternal feelings towards the child were characterized in security, insecurity and/or fear, presence and types of doubts about childcare.

Variables related to lesions were moment of appearance (from 1 to 7 days; from 8 to 14 days; from 15 to 21 days and more than 21 days), the type (erythema, bruise, petechiae, papule, vesicle, bubble, pustule, erosion, fissure, excoriation, taint, plaque, weal, spot, crust, scale, other and more than one lesion) and place (cephalic region, mouth, neck, anterior thoracic region, posterior thoracic region, right upper limb, left upper limb, abdominal region, umbilical stump, genital region, lumbar region, perianal, right lower limb, left lower limb, other and more than one place).

To classify skin lesions it was used a memento containing the main skin lesions and their definitions4.To childcare analysis it was used as reference orientation in specific litearture10,11.

Data were formatted and analyzed using Epi Info version 6.04 software. A descriptive analysis was used to variable characterization. Association between skin problems in newborn/breast-fed and variables of the child, maternal, dwellings, prenatal care and maternal care was evaluated through Qui-Square (x2) Test and Fisher’s Exact Test when expected numbers were smaller than five, considering a level of significance of 5%.

The research was approved by the Ethics Board in Research involving human beings of the Center of Health Sciences of the Federal University of Pernambuco in November, 08th, 2011, protocol number 273/11, respecting Resolution nº 196/96 of the National Board of Ethics in Research.

RESULTS AND DISCUSSION

In this study, 87(82,9%) children were newborns and 18(17,1%) were breast-fed. As for gestational age, 11(10,8%) kids were born premature, 87(85,3%) at full term and 4(3,9%) were post-term.  Gestational age was not registered in the hospital leave summary in 3 cases, according to Table 1. Referring to sex, 57(54,3%) were males and 48(45,7%), females.

Regarding skin lesions, 81(77,1%) of the kids had lesions. In 59(77,6%) of the children, lesion appeared between 1 and 7 days before data collection, in 11(14,5%), between 8 and 14 days, in 3(3,9%), between 15 and 21 days and in 3 (3,9%), more than 21 days. In five cases mothers did not know when the lesions appeared. The fact that the majority of lesions appeared in the two first weeks of life is preoccupying as simple measures of care can prevent them8.

A more sensitive and more keratinized skin, characteristic of prematurity, favors the appearance of lesions in premature newborns12.Notwithstanding, in this study it was verified high prevalence of skin lesions independent of gestational age and bigger in breast-fed 15(83,3%) when compared to newborns, setting itself as a relevant problem in newborns and breast-fed care5, as shown in Table 1.
AQUI TABELA 1
In relation to number of lesions, 42(51,9%) kids presented a single lesion and 39(48,1%) two or more different lesions. Among the types of lesions it was observed that 38(46,9%) kids had papule, 35(43,2%)scales, 27(33,3%) erythema, 11(13,6%) crust, 6(7,4%) pustule, 5(6,2%) plaque, 3(3,7%) vesicle, 3(3,7%) erosion, 2(2,5%) fissure, 2(2,5%) excoriation, 1(1,2%) bruise and 1(1,2%) spot.

The types of lesions differed from those found in a study conducted in the same health unit in 20068, that showed as the more frequent lesions: erythema (37,15%), papule (29,57%), crust (7,62%) and pustule (6,66%).

As for the area of the body where lesions were found, 50(61,7%) kids had lesions in the cephalic region, 25(30,9%) in lower limbs, 23(28,4%) in the genital area, 15(18,5%) in perianal and in 50(61,7%) lesions were found in more than one place.

As for regions where skin lesions are usually found, research conducted in Fortaleza-CE pointed face (34%), forehead (29%), superior limbs (13%), stomach (8%), inferior limbs (8%), ear and gluteus (4%) respectively, as the more common13.This research corroborates his study in which the place more common to lesions was the cephalic region.

A study in newborns conducted in the emergency of a pediatric hospital14, identified that 18,5% of medical care occurred due to skin lesions. That is a motive that worried most the parents, and, in the majority of cases, those are situations of low complexity that do not justify emergency care.Common lesions in newborns can unnecessarily preoccupy parents and professional, as they are benign, transitory and do not demand therapy.Eventhough, they need to be evaluated and differentiated from pathological lesions, to direct the professional’s approach and calm the parents down15.

Regarding maternal variables, 21(20%) were teenagers, 33(31,4%) were married, 17(16,2%) were single, 54(51,4%) lived in a stable union andone mother was divorced. The number of teenage mothers in the study was similar to the proportion of live births from teenager mothers registered in Brazil in 200816. It is considered a risk factor being born from a teenage mother, due to maternal immaturity in bio-psychosocial aspects16.

As for maternal formal education, it was observedthat 85(85,7%) had 8 years or more of formal education, education that could contribute to adequate care to children17.Even though, in this study being an adolescent mother or having less formal education was not associated to the appearance of skin lesions in kids, as presented in Table 1.As for the number of children, 49(46,7%) of the mothers said that the child examined was the first kid, 44(41,9%) had two or three kids and 12(11,4%) had four or more kids. Experience with other kids care could have contributed to the prevention of lesions, what, in this study, was not observed. In this sense, numerous families, with more than three kids, demand from the mothers bigger time distribution dedicated to the care of kids’ basic needs17.

Concerning to the number of prenatal consultations and to orientation given about newborn care, 74(77,3%) had six or more consultations, as recommended by Health Ministry18, only one mother did not attend to prenatal, and 88(84,6%)of them did not receive orientation. Among the mothers that were orientated, 8(50%)were informed about kids bathing, 2(12,5%)about hygiene products, 3(18,8%) on general careand 3(18,8%) on sunbathing. It is considered preoccupying the fact that the majority of mothers did not receive any orientation about childcare; such situation characterizes a gap in prenatal assistance, as the Health Ministry recommends the approach about childcare during gestation18. It shall be highlighted that 13(81,3%) kids, from the mothers that had orientation, had some skin lesion, pointing to the need of reflection on educative actions developed by health professionals, according to Table 1.

Referring to water, 101(96,2%) mothers used treated water. In 103(98,1%) households garbage was collected, 99(94,3%) had piped waterand 95(90,5%) basic sanitation. It was observed that kids in which households there was no piped water had bigger prevalence of lesions 5(83,3%), suggesting that the water used to childcare was not, probably, treated.

As for number of baths, 63(60%) mothers informed only a daily bath.In the first month of life, bath can be daily, however, in hotter regions, such as Northeast of Brazil, place where the research was conducted, frequency can be increased10. In these regions it is common that kids have miliaria and scrofulous, and papule is a characteristic lesion of these skin problems8, and the commonest in this research.

To the correct bathing, some orientation needs to be given to mothers.Face and head shall be bathed first (before the kid is taken to the bathtub), and after being dried, the rest of the body is cleaned with the kid still in the bathtub10. In this study was observed that 77(73,3%) mothers bathed correctly, fact that can contribute to the prevention of skin problems.

As for products used in bathing, 101(96,2%) mothers used kids soap and 21(20%) more than one product. Shampoo was used by 22(21%) mothers and conditioner by 6(5,7%). It was found that 19(86,4%)kids whose mothers used shampoo presented lesion in their scalp and all kids had lesions with the use of conditioner, as described in Table 2. Associated to this cause, mothers’ fear to cause damage to kids through friction in the bregmaticfontanelle (anterior fontanelle), can worse the problem. In this study the second kind of lesion and more prevalent spot were scales and scalp, respectively.
AQUI, INSERIR TABELA 2
All mothers used disposable diapers, which shall be preferentially adopted, as they are super-absorbent and keep dry the genital area1, avoiding lesions. However, some authors recommend alternate disposable diapers with cotton diapers, so the child’s skin stay airy10.

Skin irritation prevention, also has relation to frequent diapers’ change and use of ointments recommended by health professional8. It was relevant the number of mothers that used ointments - 97(92,4%), and that had this care every change of diapers - 88(90,7%), indicating their worry towards lesion prevention in this area. Change of diapers after diuresis 1must be encouraged, an attention not taken by 26(24,8%) of those interviewed, and from this percentage, 22(84,6%) kids developed lesions, according to Table 2. It was also observed that all of them changed diapers after evacuation.Keeping diapers umid, with its full capacity of absorption, exposes the child’s skin to direct contact with urine, and may cause irritation1.

In order to do hygiene of the child’s genitals, 70(66,7%)mothers used baby wipes, 18(17,1%) cotton and lukewarm water and 17(16,2%) baby wipes and lukewarm water, as presented in Table 2; as for the technique, 95(90,5%) used it correctly.
It was observed that baby wipes was largely used for genitals hygiene, in a bigger percentagethan the one previously observed in a study with the same population in which 42(28,6%) mothers used the product to genital area hygiene of their children8. Preoccupying fact as 55(78,6%) children of this study that used the product had lesions, as described on Table 2. So, it shall be encouraged the use of cotton and lukewarm water11,discouraging the use of baby wipes, that, in spite of being practical can cause irritation10.Erythema was the third commonest lesion in this study, characteristic lesion due to dermatitis in diapers area and irritation due to chemical products8.

Other aggravating fact observed in the study is related to the use of perfume in 82(78,1%) kids, productconsidered toxic as it provokes skin irritation8. Use of perfume in babies seems to be cultural, being used since birth. It is worth mentioning that in a previous study conducted in the same hospital, in 2006, only 14,28% of the kids used perfume8.

In relation to care with kids’ nails, only 32(30,5%) mothers kept them cut. As a measure of prevention of skin integrity it is important that kids’ nails are kept short, to avoid bruising their own skin1. In this study the numbers seem to show the insecurity and/fear mothers feel about this aspect of childcare.

About products used to wash children clothes, 26(24,8%) mothers used poder soap and softening, 18(17,1%) coconut bar soap and softening and also half the mothers- 50(47,6%) –used only coconut bar soap, according to Table 2, differently from similar study8, in which just 23,53% admitted use this product.

It was also observed that, when combining any of those products, powder soap, bar soap and even coconut bar soap with the softening, more than 80% of the children developed lesions, as presented in Table 2. The same happened with single use of powder soap - 6(85,7%). It must be highlighted the need for orientation on products to be avoided when washing kids’ clothes. Just water and neutral soap are recommended, besides, clothes must be washed separately, rinsing many times in order to eliminate soap residues and ironed with hot iron.Use of clothes softening and bleaches are discouraged as they can damage kids’ skin10, that due to immaturity of the integumentary system, presents more sensitivity to chemical products and permeability to toxic agents4.

There was a bigger occurrence of lesions in children whose clothes were not washed with coconut bar soaps when compared to those that had just this product used, 46(83,6%) and 35(70,0%), respectively, as shown in Table 2, indicating this product as the most indicated to clean kids’ clothes10.

Kids’ skin lesions are also associated to insect stings, being possible evolving from itching and local irritation to papules and vesicles, characteristics of scrofulous, besides pain and discomfort19. It was observed that 51(48,6%) kids were exposed to insects; so, action is fundamental to avoid contact of those with kids, with use of mosquito nettings to night and day protection19. The majority of kids in this study - 95(90,5%) – used this protection. However it cannot be affirmed that this care was continuous in all environments the kidscoud be found.

Referring to use of repellent or medicine in the kids’ skin, just 3(2,9%) interviewed admitted they used children repellent. Skin repellent shall not be used in kids younger than six months19.

As for support in childcare, it was observed that 92(87,6%) mothers were helped, more than half- 51(55,4%)–by the kids’ grandmother, 23(25%) by their companions and 4(4,3%) by other caregivers, according to Table 3, differently from study conducted in Almada, Portugal, in 200714, in which it was shown that 71% of the mothers had support from the father of the child in childcare. INSERIR TABELA 3
In this study it was observed that 78(74,3%) mothers felt safe, reporting positive feelings towards childcare, as described on Table 3. Similar data was found in a study conducted in São Paulo in 2008, in which positive feelings were more frequent. However, faced with the situations that involved difficulty and new experiences, mainly related to bathing and nightly periods, mothers reported fear20, fact observed in 27(25,7%) of those interviewed in this study.

In spite of high prevalence of skin lesions in this research, just 7(6,7%) mothers voiced doubts towards childcare. Among those, 1(14,3%) had doubts as for oral hygiene, 3(42,9%) related to genital area hygiene, 1(14,3%) related to products used in hygiene, 1(14,3%) on general careand 1(14,3%) on sunbathing, as show on Table 3. Similar data, obtained in study conducted in Fortaleza-CE, reinforce the need for orientation and clarification on childcare15.

Existence of support to take care of the child and motherly feelings towards this care did not presente significant statistic results, however, when we correlate the presence of skin lesions with support to take of the child, it was observed that 11(84,6%) kids whose mothers did not have any help presented lesions, as shown in Table 3. This fact can be related to the performance of other daily tasks21, to the number of kids and to inexperience in case of primiparous22.

CONCLUSION

Skin problems had high prevalence in newborn and breast-fed in the hospital studied.We can infer that maybe this relation was influenced by products used in body hygiene and children clothes.

It was expressive and preoccupying the use of chemical products and cosmetics by mothers in childcare in this study. The same can be said for the adoption of inadequate practices, as for hygiene habits. This result suggests that nursing actions on childcare shall involve orientation of caregivers towards skin care and lesion prevention, with recommendation of the correct practices related to child’s hygiene, as well as clothes and utensils’ hygiene.

We expect that results generated can have a positive impact on clinical practice, warning professionals about the need of educative actions to keep the skin integrity of the kids with orientation scientifically based, provided during prenatal.

One of the limitations of the study was the use of intentional sampling, which restricts the power of generalization of the results. So we suggest that others studies shall be conducted with representative samplings that allow multiple statistical analysis in the investigation of determinants to skin lesions in children.

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Direitos autorais 2013 Albaneide dos Santos Ferreira, Ana Letícia Cabral Interaminense Guerra, Marly Javorski, Suely de Fátima Santos Freire Bonfim, Thaís de Almeida da Silva, Luciana Pedrosa Leal, Luciana Pedrosa Leal

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