As a nurse in the neonatal intensive care unit for many years, I witnessed a change in management of infants who were experiencing respiratory distress syndrome. Over the years there has been an increase in the use of nasal prong continuous positive airway pressure (NPCPAP) as a treatment. Nasal prong continuous positive airway pressure is a medical device that applies pressure to the nose, which can cause tissue ischemia. Neonates are more vulnerable to pressure injury because of their absence of subcutaneous fat under the skin, leaving the epidermis and dermis directly on top of each other. Currently, we do not know which interventions are most effective in reducing pressure and maintaining skin integrity when using medical devices such as NPCPAP ventilation.

Although NPCPAP was less invasive, it was difficult for nurses to manage the placement of the NPCPAP prongs and heavy tubing to keep them stable because the prongs would come out when the baby moved. This resulted in injuries to the nose that were difficult to treat especially when they still required NPCPAP ventilation. There is a need for more evidence in pressure injury prevention among children, as there is great variation between premature, term, infants, toddler, preschool, school age, and adolescent skin.

Recent studies have included neonates in their pediatric pressure injury prevalence studies, but we have little information about neonatal prevention by intervention, level of care, or by age group. It has been reported recently that neonates had a 34.7% injury rate from NPCPAP, most were stage I or II, with a few deep tissue injuries especially in those less than 32 weeks' gestation.1 A deep tissue injury presents as a dark discoloration or bruise on intact skin. In a study of pediatric critical care unit (PCCU) patients requiring nasal cannula fixation devices, there was a higher risk for medical adhesive device injury in areas of higher moisture such as around endotracheal and nasal fixation devices.2 The most common cause of skin injury with medical adhesive use was from skin stripping, which decreases the tissue tolerance if not performed carefully. Furthermore, intervention strategies such as offloading pressure by elevating the tracheostomy tube has been found to be effective in decreasing pressure injuries in PCCU patients.3

Prolonged exposure to moisture diminishes epidural tissue strength. Global guidelines from the National Pressure Ulcer Advisory Pane, European Pressure Ulcer Advisory Panel, and Pan-Pacific Pressure Injury Alliance4 recommend keeping the skin clean and while also protecting the skin from excessive moisture. A few studies have provided evidence for need for frequent skin inspection, gentle use of medical adhesive products, use of moisture management, and offloading direct pressure on the skin with medical devices such as NPCPAP as pressure injury prevention interventions in younger patients. In this issue, the study by Boyar and colleagues provides further evidence that frequent skin assessment and moisture management in combination with specific offloading techniques for younger patients who need NPCPAP is vital.

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