My earliest memory of preventing skin injury is from over 20 years ago when the neonatal nurses asked for an ethics review regarding the care of a micro-preemie born at 23 weeks' gestation and weighing only 510 g. As a new nurse, I observed nurses discuss how the tape was "too strong," the equipment was "too big," and the cause of disfigurement from the adhesives and equipment was largely unknown.

During my professional travels, I have spoken with WOC and neonatal nurses from across the globe and observed that preventing skin breakdown is a priority and a passion for many colleagues. This passion inspires hospital work groups and cross-collaboration with work groups coming together to dive deep into the challenge of preventing skin breakdown. These collaborations have also been formalized by associations such as the Children's Hospital Alliance, Solutions for Patient Safety, and the International Society of Pediatric Wound Care. These collaborations, along with the collective voices of many clinicians, have inspired industry partners into action and increased recognition that neonates and premature neonates require equipment unique to their size and fragility.

Despite these advances and the growing awareness of the clinical relevance of pressure injuries in neonates, challenges persist. One of these challenges is the applicability of the current National Pressure Ulcer Advisory Panel (NPUAP) pressure injury staging system when applied to the premature neonate.1 A second challenge relates to unique issues faced by neonates including recognition that some may occur in utero because of pressure created when maternal bony structures press against the fetus when amniotic fluid volume is diminished. This issue is addressed in a Clinical Challenges article appearing in this issue of the Journal of Wound, Ostomy and Continence Nursing authored by Deanna Johnson, titled "Recognizing Congenital Pressure Injuries: A Case Series."

The paucity of knowledge that Johnson discusses in the area of congenital pressure injuries points out the ongoing need for WOC and other neonatal clinicians to generate additional research in this area and to reach consensus concerning existing evidence and classification schemas when applied to neonates. While these tasks may appear daunting on the first consideration, the scholarly efforts of Baharestani and Ratliff2 provide an excellent basis for gaps in our knowledge and a foundation for future scholarly work.

I suggest beginning with a fundamental question, are we accurately identifying the cause of pressure injuries present at birth? In my clinical practice, I was frequently consulted to stage and treat a presumed pressure injury in a premature or full-term neonate. Even though I assessed these neonates within 24 hours of consultation, I usually saw the patient at least 24 hours after birth and was often aside to stage a pressure injury as long as 3 to 5 days after birth when the lesion was initial observed. Having read Johnson's article and considering this issue in hindsight, I question whether I accurately identified the cause of the pressure injury. I further urge WOC and other nurses who care for neonates to question whether the NPUAP staging system applies to full-term and premature infants and, secondly, whether skin compromise may indeed begin in utero. I assert that we should consider a staging system for neonates that more fully considers the effects of prematurity on skin development and the impact of in utero factors on skin integrity. Understanding the cushioning impact of amniotic fluid compromise and maternal factors on the neonate in utero may facilitate identifying high-risk neonates. At the very least, we need to explore these concepts and build on the scholarly foundation provided by our colleagues.

Despite infants' ability to rapidly generate keratinocytes, the permanent disfigurement and altered functionality associated with full-thickness pressure injury in extremely low-birth-weight infants (mirco-preemies) are substantial.3 However, many injuries impacting extremity function have been prevented as a result of the scholarly efforts of preventing skin injury.3 I challenge all WOC and other nurses who care for premature and full-term neonates to consider these challenges, to engage in research, and to support efforts to improve identification of premature and full-term neonates at risk for pressure injury, to prevent these lesions whenever possible, and to consider the unique risk factors and physiology that characterize pressure injury development in this vulnerable population.

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