Preterm, critically ill neonates represent a challenge in wound healing. Many factors predispose infants to skin injuries, including decreased epidermal–dermal cohesion, deficient stratum corneum, relatively alkaline pH of skin surface, impaired nutrition and presence of multiple devices on the skin. We present a case series describing the use of medical-grade honey—Leptospermum honey (Medihoney), for successful treatment of slowly healing neonatal wounds, specifically stage 3 pressure ulcer, dehiscent and infected sternal wound, and full-thickness wound from an extravasation injury.
There is an increased awareness that premature babies and neonates born with congenital defects are at increased risk for skin breakdown. Many factors predispose neonates to skin injuries, including decreased epidermal–dermal cohesion, deficient stratum corneum, more alkaline pH of skin surface, poor nutrition, relatively immature immune system and large areas exposed to equipment. As technology brings cure, it also brings risk factors, such as adhesives that strip epidermal layers, catheters that increase risk for extravasations and devices that place pressure and friction stress on vulnerable skin.
In our experience, hydrogel covered with hydrocolloid or silicone dressing is often sufficient to heal neonatal skin breakdown, but occasionally stalled or difficult-to-treat wounds present a diagnostic challenge. Recently medical honey gained attention in the adult community as a treatment for various dermatologic conditions. We introduce a new approach (for the neonatal community) to treatment of various neonatal skin breakdowns using active Leptospermum honey, a medical-grade honey (Medihoney Derma Sciences, Princeton, NJ, USA), the only honey cleared by FDA for treatment of various dermatologic conditions in adults. There are no known contraindications for pediatric or neonatal use, other than allergy to honey. We present three successfully treated cases, including stage 3 pressure ulcer, dehiscent and infected sternal wound, and extravasation-related full-thickness wound.
Case 1. Stage 3 pressure ulcer
Three-month old, former 28-week gestation male born with double outlet right ventricle, VSD and right ventricular outflow tract obstruction. On DOL#80, he was taken to the catheterization lab for ballooning of the pulmonary valve. After the procedure he experienced decreased pulses on the right lower extremity with delayed capillary refill. Treatment included low-dose heparin, followed by low molecular weight heparin. Two weeks into this treatment, a right leg stage 3 pressure ulcer was noted in the lower right calf (Figure 1a). His initial treatment involved application of hydrogel covered by a hydrocolloid dressing. After two weeks of such treatment and minimal improvement, Medihoney gel, covered with Medihoney infused hydrocolloid (MHCS) and an outer dressing was initiated. Medihoney gel was applied every three days for the first two weeks. By the end of the second week substantial granulation and new epithelialization was noted. The dressing application was changed to once a week, and by the end of the fourth week the wound was closed, with increasing natural pigment distribution and soft scar (Figure 1b).
Case 2. Dehisced and infected surgical wound
Three-month old, former 36-week gestation female was born with a diagnosis of hypoplastic left heart syndrome, double outlet right ventricle, unbalanced AV canal and partial trisomy 16. Following the first stage Norwood repair and Sano shunt placement at two weeks of age, she developed a sternal wound dehiscence and secondary bacterial infection. The wound measured 2 × 11 cm with slough, exudate and sternum exposure. Initially hydrogel covered by silicone dressing was used without success. After 10 days, continuous negative pressure wound therapy at 50 mm Hg was started. Minimal slough removal and few new granulation areas were noted after two weeks (Figure 2a). Negative pressure wound therapy was discontinued. Medihoney gel along with MHCS were applied to the area and covered with silicone dressing. The dressing was changed every three days. Noticeable improvement was seen in the first week and the wound had completely healed by week three (Figure 2b).
Case 3. Full-thickness wound from extravasation injury
Three-week old former 26-week female was born due to preterm labor and maternal sickle cell disease crisis. At three weeks of age, a stage 4 right ankle peripheral IV extravasation injury was found. For the first 24 h it presented as a large, fluid-filled bulla. The bulla ruptured the following day and evolved into full-thickness wound, with areas of slough and exudate. Medihoney gel was started on day 2, covered by a hydrocolloid dressing. It was reapplied every 3 days for the first 10 days. New granulation tissue and decrease in exudate were noted by day 6. Less discomfort with motion and less periwound edema was noted as well. After 10 days dressing was changed once weekly, and by 3 weeks the wound had healed with full range of motion and soft pink scar.
Preterm neonates represent a unique group of patients as their immature skin, compromised perfusion, limited mobility, suboptimal nutritional status and need for multiple devices may lead to slow wound healing. Treatment for pressure ulcers, extravasation injuries and dehisced wounds often involves application of hydrogel/hydrofiber, covered by ether hydrocolloid or silicone dressing. The aim is to fill dead space, maintain moist wound environment, induce new epithelial tissue growth and protect the wound from infection and trauma. Stage 1 and 2 pressure ulcers or partial thickness wounds should show evidence of healing within 1 to 2 weeks, while stage 3 and 4 ulcers/full-thickness wounds should show evidence of healing within 2 to 4 weeks.1, 2, 3 Specifically for ulcers it has been demonstrated that healing less than 0.1 cm per week predicts high risk for non-healing at 6 months.4 There are various reasons for poor healing, including impaired perfusion and oxygenation, non-resolved inflammation, presence of proteases and recurrent physical trauma.
The use of medical-grade honey in wound healing has been traced many centuries back to Medieval Europe and ancient Egypt. The unique properties of medical honey explain its ability to treat various types of skin injuries.5, 6, 7 Honey is a mixture of bee saliva and nectar. We know that honey is about 20% water and 80% sugar, with certain enzymes added by the bees.8 Medihoney Antibacterial Wound gel consists of 80% Leptospermum honey, 15% Myristyl Myristate and 5% Plantacare (natural vegetable derived esters for emulsification and stability). Leptospermum honey is known to possess specific properties that make it an ideal therapeutic agent. It possesses antimicrobial activity due to its high osmolality (high sugar content) which suppresses bacterial growth. One of the enzymes added, glucose oxidase, converts glucose to gluconic acid, making the honey’s pH (3.5 to 3.9) too acidic for bacteria.7, 8, 9 Bees add natural hydrogen peroxide to the honey and naturally occurring phytochemicals also are thought to be antibacterial. Honey decreases natural biofilm formation. It has an anti-inflammatory activity because the high osmolality of the honey draws water out of the wound and reduces edema. Lastly, it is autolytic because it creates moist environment that enhances autolysis; increasing lymph fluid that delivers plasminogen. Plasminogen is converted to plasmin thereby increasing degradation of fibrin strands in the slough. Medihoney undergoes gamma irradiation to inactivate any microorganisms that may be present, such as Clostridial spores.10
During our case series, we dealt with very compromised, critically ill preterm babies. Medihoney products demonstrated ease of use, decreased pain with dressing changes, timely wound closure and no side effects in our patients. For these reasons, Medihoney was added to our formulary. Recently, we started using honey products as a first-line therapy for stage 2 and higher pressure ulcers, extensive extravasation injuries and open surgical wounds. Time to closure seems superior to previous practice (hydrogel plus secondary dressing). This may translate to cost advantages. We recommend considering medical-grade honey when faced with difficult-to-treat neonatal/pediatric wounds.
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The authors declare no conflict of interest.
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Boyar, V., Handa, D., Clemens, K. et al. Clinical experience with Leptospermum honey use for treatment of hard to heal neonatal wounds: case series. J Perinatol 34, 161–163 (2014). https://doi.org/10.1038/jp.2013.158
- Medihoney gel
- skin breakdown
- wound healing
- wound dehiscence
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