Skin Safety During EEG Procedures Addendum: Neonatal Continuous EEG

ASET Position Statement
Skin Safety During EEG Procedures – A Guideline to Improving Outcome
Addendum: Neonatal Continuous EEG
The Skin Safety Guideline developed by the Skin Safety Task Force (SSTF) and approved by the ASET Board of Trustees in 2015 provides instruction in attaching surface electrodes for continuous electroencephalogram (EEG) on adults. In 2016, the task force determined additional guidelines would be beneficial for patient subgroups, such as pediatrics, neonates, and those with skin conditions. The SSTF was directed to develop addenda for the existing guideline to address these special patient groups. Due to the level of work established by the previous task force, it was determined to be advantageous to form separate subcommittees to address each issue. The SSTF began with developing addenda for neonates and patients with dermatologic skin conditions; this addendum addresses neonatal patients undergoing continuous EEG.  
Neonatal EEG is defined as an EEG performed between birth and the first 4 weeks of life up to and including 44 weeks gestational age. Many of these patients are premature and may have serious or even life threatening complications. It is crucial that EEG Technologists do not cause additional injury to these patients through over preparation of the skin, failure to monitor the skin condition around and under the electrodes, or failure to respond quickly to changes in the condition of the skin.
It is important that every technologist understand and document the infant’s age according to the following terms in order for physicians to properly evaluate the EEG of neonates.
  • Gestational age (GA) – time in weeks from conception to the infant’s birth
  • Conceptional age (CA) – GA plus time in weeks since birth
  • Premature infant – born before 38 weeks GA
  • Full-term infant – born 38–40 weeks GA
  • Newborn period - first 4 weeks after term
  • Infantile period - between 5 and 12 weeks after term
A thorough literature review was conducted by members of the subcommittee. Over 40 scientific articles were reviewed based on the following criteria: skin breakdown, pressure ulcers (PU), medical device related pressure ulcers (MDRPU), hospital acquired pressure ulcers (HAPU), medical adhesive related pressure ulcers (MARPU), electroencephalogram (EEG) and neonates. 
Existing Guidelines
Existing guidelines and assessments regarding the care of neonate patients and continuous EEG include: ACNS Guideline 13, Braden Q (only ages 3 weeks to 8 years), Glamorgan scale, Neonatal Skin Risk Assessment Scale (NSRAS), and Association of Women’s Health, Obstetric and Neonatal Nurses (AWOHNN) recommendations. 
The American Clinical Neurophysiological Society (ACNS) guidelines instruct technologists in setting up continuous EEG on neonatal patients, but do not address skin safety (Shellhaas et al. 2011).  In 2016, the ACNS released new guidelines raising the acceptable impedance limit to 10 kOhms, which will help to reduce skin breakdown.
The Braden Q Scale is intended for pediatric patients ages 3 weeks to 8 years and is designed to identify patients at risk for skin breakdown, but not breakdown due to medical devices such as electrodes. 
Glamorgan Scale is intended for patients birth to age 18 years. The Glamorgan scale is the only pediatric PU risk assessment scale addressing medical devices. It has been researched by several European groups and the sensitivity, specificity, and inter-rater reliability score higher than any other pediatric PU risk assessment scale (Baharestani and Ratliff 2007, Sterken et al. 2015, Kottner et al. 2010, August et al. 2014, Apold et al. 2012, Noonan et al. 2006). 
The NSRAS and AWOHNN recommendations are mentioned briefly in literature and are not as specific or sensitive as the Braden Q or Glamorgan scale (Dolack et al. 2013, Huffines et al. 1997, Baharestani and Ratliff 2007). Other lesser known scales are being reviewed and researched constantly in hopes that an ideal scale will be uncovered. According to international research, the Glamorgan Scale is the most ideal scale in existence at this time. It is the only scale to incorporate medical devices as a risk for PUs (Anthony et al. 2010). 
Common Risks for Neonates  according to Murray et al. (2013), “Head is proportionately larger in infants than in children, teens and adults, becoming a primary pressure point for occipital pressure ulcers. This same article reports that medical devices, items used to secure medical devices, and the moisture that forms between those layers increase risk for pressure ulcers. 
Adding to those risks, “securements that are applied circumferentially can significantly increase risk of injury” (Murray et al. 2013). Neonates often suffer from fluid imbalances which lead to swelling in tissues. This process causes devices that were fit properly initially to tighten over time and cause constriction to the tissue with prolonged exposure. EEG leads rank 6 of 18 identifiable causes for hospital-acquired pressure ulcers according to Murray et al. (2013).
“We must remember that the greatest risk factor for PUs between hospitalized neonates is the belief on the part of health professionals, that the PUs are not a problem in neonates” (Garcia-Molina and Balaguer-Lopez, 2014). 
Instructions Specific to Neonates
Several large groups have published in depth instructions regarding methods of assessing newborn skin to avoid pressure ulcers or breakdown and a few have addressed medical device-related Pus, but only 2 found addressed EEG specifically. A recent study published in Acta Paediatrics by Lloyd et al. (2015) clearly outlines a step by step method for conducting an EEG in the neonatal ICU (NICU) for preterm infants (Lloyd et al. 2015).  A study by Lund et al. (2014) published in the Newborn and Infant Nursing Reviews (NAINR) refers to EEG specifically and the skin breakdown issues that arise with the use of medical adhesives (Lund et al. 2014). McNichol and colleagues address electrodes specifically, as well as other medical adhesive-related skin injuries (MARSI) and published a consensus statement addressing the assessment, prevention, and treatment of MARSI (McNichol et al. 2013). 
Per Lloyd et al. (2015), the ideal process is as follows:
  1. Pre-labelled, pre-gelled, flat, cloth like electrodes, bundled and plugged into the amplifier/breakout box.
  2. Mefix or other gentle medical tape, approved for newborns, cut into 1 inch squares.
  3. Gently apply skin prep to the head with light pressure using a cotton tip applicator or a gloved finger. Then remove prep gel with gauze square.
  4. Apply all electrodes to one side of the head. Turn the head and apply electrodes to opposite side of head.
  5. Secure with a CPAP hat or gauze cap to secure leads.  Ensure that two fingers can fit easily between cap and infants head to allow for swelling.
  6. When removing, take great care to slowly and gently remove tape to avoid skin tearing.
See Lloyd et al. 2015 article for photographs and details (available for free access at: It is imperative that steps are taken to minimize movement of the baby’s head to reduce stress to the baby. It is also of premier importance to remove all traces of prep solution and any adhesives to prevent further skin injury, such as anetoderma of prematurity and calcinosis cutis (Cheng et al. 2011). Cheng et al. (2011) also suggest that only gold disposable electrodes be used for neonates as this helps to prevent burns in the isolettes. 
Future of Continuous EEG in Neonates
Many researchers are developing caps and electrodes to alleviate prepping of multiple sites and to avoid gels and pastes on newborns. Their delicate, still-developing skin requires contact with as few substances as possible until it is fully developed. The newborn skin can absorb chemicals easily and suddenly become toxic to these chemicals resulting in permanent scarring or infection. Fridman et al. (2016), Löfthede et al. (2012) and Mullen et al. (2015) are only a few of the many researchers striving to improve the lives of newborns through improving products we use every day. 
Works Cited
  1. Anthony D, Willock J, Baharestani M. A comparison of Braden Q, Garvin and Glamorgan risk assessment scales in paediatrics. J Tissue Viability. 2010 Aug;19(3):98–105.
  2. Apold J, Rydrych D.  Preventing device-related pressure ulcers: using data to guide statewide change. J Nurs Care Qual. 2012 Jan-Mar;27(1):28–34.
  3. August DL, Edmonds L, Brown DK, Murphy M, Kandasamy Y.  Pressure injuries to the skin in a neonatal unit: fact or fiction. J Neonatal Nurs. 2014 Jun;20(3):129–37. 
  4. Baharestani MM, Ratliff CR. Pressure ulcers in neonates and children: an NPUAP white paper. Adv Skin Wound Care. 2007 Apr;20(4):208, 210, 212, 214, 216, 218–20. 
  5. Berlin F[AB1] , Carlile JA, de Burgo MI, Rochon A, Wagner EE, Sellers MC, Worrell AR, Andal EL, Woods LR. Technical tips: electrode application and preventing skin breakdown techniques. Am J Electroneurodiagnostic Technol. 2011 Sep;51(3):206–19.
  6. Cheng CE and Kroshinsky D. Iatrogenic skin injury in hospitalized patients. Clin Dermat. 2011 Nov-Dec;29(6):622–32.
  7. Csoma Z, Meszes A, Mader K, Kemény L, Tálosi G. Overview of dermatologic disorders of neonates in a central regional intensive care unit in Hungary. Pediatr Dermatol. 2015 Mar-Apr;32(2):201–7.
  8. de Lima EL, de Brito MJ, de Souza DM, Salomé GM, Ferreira LM. Cross-cultural adaptation and validation of the neonatal/infant Braden Q risk assessment scale. J Tissue Viability. 2016 Feb;25(1):57–65.
  9. Dolack M, Huffines B, Stikes R, Hayes P, Logsdon MC. Updated neonatal skin risk assessment scale (NSRAS). Ky Nurse. 2013 Oct-Dec;61(4):6.
  10. Fridman I, Cordeiro M, Rais-Bahrami K, McDonald NJ, Reese JJ Jr, Massaro AN, Conry JA, Chang T, Soussou W, Tsuchida TN. Evaluation of dry sensors for neonatal EEG recordings. J Clin Neurophysiol. 2016 Apr;33(2):149–55.
  11. Garcia-Molina P and Balaguer-Lopez E. The risk assessment scales are an efficient tool in the prevention of pressure ulcers in hospitalized neonates. J Neonatal Biol. 2014 3(4):151.
  12. Hogeling M, Fardin SR, Frieden IJ, Wargon O. Forehead pressure necrosis in neonates following continuous positive airway pressure. Pediatr Dermatol. 2012 Jan-Feb;29(1): 45–8.
  13. Huffines B, Logsdon MC. The Neonatal Skin Risk Assessment Scale for predicting skin breakdown in neonates. Issues Compr Pediatr Nurs. 1997 Apr-Jun;20(2):103–14.
  14. Jarrar R, Buchhalter J, Williams K, McKay M, Luketich C. Technical tips: electrode safety in pediatric prolonged EEG recordings. Am J Electroneurodiagnostic Technol. 2011 Jun;51(2):114–7
  15. Kawakita T, Reddy UM, Landy HJ, Iqbal SN, Huang CC, Grantz KL. Neonatal complications associated with use of fetal scalp electrode: a retrospective study. BJOG. 2016 Oct;123(11):1797–803.
  16. Kenner C. Council of International Nurses, Inc. (COINN) Update. Newborn Infant Nurs Rev. 2014;14:133–4.
  17. Kohr LM, Curley MA. Small study finds 27.7% prevalence of pressure ulcers in paediatric hospitals in Switzerland, with many cases caused by external medical devices.  Evid Based Nurs. 2010 April;13(2):58.
  18. Kottner J, Wilborn, Dassen T. Frequency of pressure ulcers in the paediatric population: a literature review and new empirical data. Int J Nurs Stud. 2010 Oct;47(10):1330–40. 
  19. Lloyd R, Goulding R, Filan P, Boylan G. Overcoming the practical challenges of electroencephalography for very preterm infants in the neonatal intensive care unit. Acta Paediatr. 2015 Feb 104(2):152–7.
  20. Löfhede J, Seoane F, Thordstein M. Textile electrodes for EEG recording – a pilot study. Sensors (Basel). 2012 Dec 7;12(12):16907–19.
  21. Lund C. Medical adhesives in the NICU. Newborn Infant Nurs Rev. 2014;14(4):160–5.
  22. McCoy B, Hahn CD. Continuous EEG monitoring in the neonatal intensive care unit. J Clin Neurophysiol. 2013 Apr;30(2):106–14.
  23. 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. J Wound Ostomy Continence Nurs. 2013 Jul-Aug;40(4):365–79.
  24. Mullen TR, Kothe CA, Chi YM, Ojeda A, Kerth T, Makeig S, Jung TP, Cauwenberghs G. Real-time neuroimaging and cognitive monitoring using wearable dry EEG. IEEE Trans Biomed Eng. 2015 Nov;62(11):2553–67.
  25. Murray JS, Noonan C, Quigley S, Curley MA. Medical device-related hospital-acquired pressure ulcers in children: an integrative review. J Pediatr Nurs. 2013 Nov-Dec; 28(6):585–95.
  26. Ness MJ, Davis DM, Carey WA. Neonatal skin care: a concise review. Int J Dermatol. 2013 Jan; 52(1):14–22.
  27. Noonan C, Quigly S, Curley MA.  Skin integrity in hospitalized infants and children. J Ped Nurs. 2006 Dec;21(6):445–53.
  28. Pallija G, Mondozzi M, Webb AA. Skin care of the pediatric patient. J Pediatr Nurs. 1999 Apr;14(2):80–7.
  29. Razmus I, Lewis L, Wilson D. Pressure ulcer development in infants: state of the science. J Healthc Qual. 2008 Sep-Oct;30(5):36–42.
  30. Reddy K, Kogan S, Glick SA. Procedures and drugs in pediatric dermatology: iatrogenic risks and situations of concern. Clin Derm. 2011 Nov-Dec;29(6):633–43.
  31. Sardesai SR, Kornacka MK, Walas W, Ramanathan R. Iatrogenic skin injury in the neonatal intensive care unit. J Matern Fetal Neonatal Med. 2011 Feb;24(2):197–203.
  32. Schmacher B, Askew M, Otten K. Development of a pressure ulcer trigger tool for the neonatal population. J Wound Ostomy Continence Nurs. 2013 Jan-Feb; 40(1):46–50.
  33. Schultz TL. Technical tips: MRI compatible EEG electrodes: advantages, disadvantages, and financial feasibility in a clinical setting. Neurodiagn J. 2012 Mar;52(1):69–81.
  34. Shellhaas RA, Chang T, Tsuchida T, Scher MS, Riviello JJ, Abend NS, Nguyen S, Wusthoff CJ, Clancy RR. ACNS guideline on continuous EEG monitoring in neonates.  J Clin Neurophysiol. 2011 Dec;28(6):611–7.
  35. Sterken DJ, Mooney J, Ropele D, Kett A, Vander Laan KJ. Become the PPUPET Master: mastering pressure ulcer risk assessment with the pediatric pressure ulcer prediction and evaluation tool (PPUPET). J Pediatric Nurs. 2015 Jul-Aug;30(4):598–610.
  36. Visscher M, Taylor T. Pressure ulcers in the hospitalized neonate: rates and risk factors. Sci Rep. 2014 Dec 11;4:7429.
  37. Visscher M. A practical method for rapid measurement of skin condition. Newborn Infant Nurs Rev. 2014;14:147–52.
--Approved by the ASET Board of Trustees, November 16, 2016

© 2020 ASET - The Neurodiagnostic Society | 816-931-1120 p |
All Rights Reserved.  Site by The Lone Designer
image widget