The skin of a premature infant can comprise up to 13% of its body weight, compared with 3% in adults. This large organ serves as a barrier to infection, protects internal organs, contributes to temperature regulation by preventing evaporative heat loss and insensible water loss, stores fat, and provides tactile sensory input. The sensations of touch, pressure, temperature, and pain are received by millions of microscopic nerve endings in the skin.

Skin is also instrumental in the initial establishment of the mother-infant relationship. Skin-to-skin contact, beginning immediately after delivery for the healthy newborn, is an important sensory experience for both the mother and the infant. When the newborn needs intensive care this may not occur initially, but hopefully can be initiated in the newborn intensive care unit (NICU).

Neonatal skin and skin care has been an important clinical concern for neonatal nurses for many years. Problems with skin integrity in the neonatal intensive care unit became noticeable as smaller, sicker, and more premature infants survived due to the technological advances in the 1970s, particularly in respiratory management and nutrition. Our first publication on the topic of neonatal skin care, "Improved Skin Care for Premature Infants" was published in 1983.1 In it we wrote of the unique anatomic and physiologic differences in neonatal and premature skin known at the time, relying heavily on the information found in the text "Neonatal Skin: Structure and Function" published in 1982.2 Much of this information is still relevant today, and we now have new information about how newborn skin functions, matures, and responds to caregiving.

Nurses who care for full-term newborns, healthy premature, and extremely premature infants have incorporated a variety of evidence-based practices in their care for the skin. In 2001, 2 nursing organizations, the Association of Women's Health, Obstetrics and Neonatal Nurses and the National Association of Neonatal Nurses published the first evidence-based clinical practice guideline for neonatal skin care.3 This guideline was extensively evaluated in 51 US nurseries involving 2820 premature and full-term newborns. Results of the evidence-based practice project that ensued included improved skin condition, changes in care practices, and increased knowledge among the nurse site coordinators about evidence-based skin care.4,5 In 2013, the third edition of the guideline was published, incorporating new research and evidence for practice changes.6

In this special issue on newborn skin care, we highlight a number of different aspects of interest to neonatal nurses. Marliese Nist describes the improved skin integrity outcomes seen after consistently implementing weekly skin rounds in the NICU over a number of years. Premature infant skin care and prevention of harm are addressed by Deanna Johnson in her article, including adhesive use, diaper care, and product use to avoid potential allergens. Safe product selection is also in an in-depth discussion by Joanne Kuller. A case study involving diaper dermatitis is presented by Media Esser, as well as her unit-based algorithm designed to standardize products and their use for this condition in the NICU population and I have contributed a review of current controversies surrounding newborn bathing practices including the daily bathing of NICU patients with chlorhexidine gluconate.

It is refreshing and exciting to see the importance given to skin care and maintaining skin integrity by neonatal nurses. Hopefully, this issue will inspire other NICUs to use skin rounds, or use skin integrity as a metric in quality improvement projects. I also hope it will stimulate more original research on skin care techniques and practices to further build our evidence. We have greatly improved how we approach skin care, but there is more work ahead.

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