EXPOSURE TO PROCEDURAL AND ENVIRONMENTAL STRESS IS COMMON IN THE NICU.([FOOTNOTE=Newnham CA, Inder TE, Milgrom J. Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale. Early Hum Dev. 2009;85(9):549-555.],[ANCHOR=],[LINK=])

Up to 16 times a day, a premature infant experiences painful or stressful procedures, often with little or no analgesia.([FOOTNOTE=De Lima J, Carmo JB. Practical pain management in the neonate. Best Pract & Res Clin Anaesth. 2010;24:291-307.],[ANCHOR=],[LINK=]) The environment itself can be very noisy,([FOOTNOTE=Brown G. NICU noise and the preterm infant. Neonatal Netw NN. 2009;28(3):165-173.],[ANCHOR=],[LINK=]) often with continuous lights and alarms that ring day and night.3,([FOOTNOTE=Peng N-H, Bachman J, Jenkins R, et al. Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU. J Perinat Neonatal Nurs. 2009;23(4):363-371.],[ANCHOR=],[LINK=]) 

NICU stresses can have significant short-term and long-term effects. Environmental stressors may affect neonate heart rate, respiration rate, and oxygen saturation.4 Procedural pain may lead to damaging effects on neural structure, function, and development as well as long-term cognitive and behavioral problems.([FOOTNOTE=Walker SM. Neonatal pain. Paediatr Anaesth. 2014;24(1):39-48.],[ANCHOR=],[LINK=]),([FOOTNOTE=Grunau RE. Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. Rambam Maimonides Med J. 2013;4(4):e0025.],[ANCHOR=],[LINK=])

 The Fragile Skin

The skin of premature infants has fewer epidermal layers and less structural support in the dermis than the skin of full-term babies.([FOOTNOTE=Visscher M, Narendran V. The ontogeny of skin. Adv Wound Care. 2014;3:291-303.],[ANCHOR=],[LINK=]) In addition, the connection between the dermis and epidermis is fragile in neonates.([FOOTNOTE=McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science: consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. Orthop Nurs. 2013;32(5):267-281.],[ANCHOR=],[LINK=]) This structural immaturity puts premature infants at risk for pain and skin injury during adhesive removal.8

For any patient, the upper layers of the epidermis may be lost when adhesive tape is removed. Due to the specific characteristics of neonatal skin, adhesive removal can cause complications in premature infants. Loss of epidermal layers during adhesive removal can compromise the structural integrity of neonatal skin, resulting in increased skin permeability to pathogens and irritants, which can lead to potential toxicity and higher risk of infection.8

#1 Cause

Medical adhesives ranked as the #1 cause of skin breakdown among NICU patients in a study of 2,820 newborns.8

The Vulnerable Brain

Preterm infants are born during a time of rapid brain development that includes development of synaptic connections and establishment of cortical networks.6 These processes are affected by pain, which puts neurologically immature infants at risk for long-lasting consequences associated with neonatal pain.6

Preterm neonates are more sensitive to touch and pain than full-term babies.6 They also experience sensitization, in which earlier interventions can affect response to subsequent stimuli.6 For example, an infant who experiences a heel lance may respond to routine handling 30 minutes later as if it were an invasive procedure.6

Exposure to pain in preterm babies has been implicated in sensitization of pain pathways, as well as long-term alterations in brain structure, function, and neurodevelopment.6 These changes may contribute to the long-term difficulties in attention, executive functions, cognition, and behavioral problems associated with premature birth.6

5% to 15%

Five to fifteen percent of very preterm infants who survive experience neurobehavioral disabilities, including cerebral palsy and severe neurosensory impairment.([FOOTNOTE=Pickler RH, McGrath JM, Reuna BA, et al. A model of neurodevelopmental risk and protection for preterm infants. J Perinat Neonatal Nurs. 2010;24(4):356-365.],[ANCHOR=],[LINK=])