Best Practices for Daily Skin Checks and Maintenance for Neonates Undergoing EEG Monitoring

A neonate with head wrap

The delicate skin of neonates must be handled with care during EEG electrode application and testing, especially during long-duration recordings.  Newborn skin can absorb chemicals easily, causing skin irritation, breakdown, and potentially, infection.  It is the responsibility of the EEG technologist to understand the special precautions necessary when recording these studies. 

In addition to technical considerations, the technologist should accurately document, among other things, the condition of the neonate’s skin during a continuous recording. 

The following recommendations have been compiled from Position Statements issued by the American Society of Electroneurodiagnostic Technologists (ASET).  Your facility may choose to include these while creating or updating your site-specific protocol.  Follow your facility’s policy and procedure manual for daily skin checks and maintenance.

Patient Head Measurement and Electrode Placement

  • It is critical that the baby’s head movement is minimized as much as possible. Apply all electrodes to one side of the head before rolling the baby’s head to apply electrodes to the opposite side.
  • If necessary, clean the baby’s skin, then lightly apply skin prep with the side of a cotton swab, gauze square, or a gloved finger, using light, quick strokes in one direction. Do not use blunt-tipped needles on babies’ scalps.
  • Wipe excess skin prep before applying electrodes.
  • Gently apply the electrode according to your facility’s protocol. If using conductive paste, allow it to “float” the electrode, keeping the metal from pressing against the scalp.  You can cushion the electrode hub/wire with a small piece of cotton or gauze to keep it from also pressing into the baby’s scalp.
  • Mefix, or other gentle medical tape approved for neonatal use, can be used to help adhere electrodes. Avoid using non-breathable tape.
  • Impedances should be balanced and maintained up to 10 kohms to avoid excessive abrasion of skin, according to 2016 Guidelines from the American Clinical Neurophysiology Society (ACNS).
  • If wrapping the head, secure the electrodes with stretchable, breathable gauze, ensuring that two fingers can easily fit between the head wrap and the infant’s scalp. CPAP hats have also been used successfully. Do not wrap the head tightly.
  • Place a small cushion or silicone gel/pack under the baby’s head/neck to relieve pressure of the electrodes on the scalp.
  • Gently remove electrodes and tape, being especially careful to avoid tearing the baby’s fragile skin.

Electrode Selection

  • Disposable, flat-rimmed disk electrodes decrease cross contamination.
  • Gold-plated electrodes do not appear to heat as much as other metals under heat lamp exposure.
  • A number of sterile, disposable, flat‐surfaced EEG electrodes, such as Incereb neon, or caps are available as alternatives.
  • Needle electrodes are not recommended for neonatal EEG monitoring.

Documenting Skin Integrity

  • Delineate roles and responsibilities of those caring for the baby’s skin (nurse, wound care specialists, and EEG tech).
  • Create a spreadsheet to track skin integrity.
  • Establish a protocol to determine frequency of electrode site examination (every 12-24 hours is recommended), as well as which electrodes should be checked each day.
  • Verify and document skin integrity with the nurse. Note any changes on the spreadsheet, as well as the EMR; both the EEG tech and nurse should initial the document.
  • Any evidence of skin change indicates the electrode site should be cleaned and electrode moved away from the original site. Adjust the homologous electrode to maintain symmetry and document, following lab protocol.
  • At end of recording after electrodes are removed, assess the skin with the nurse and document its condition.

The FL.E.S.H. Scale, produced in 2013 by the University of Florida Health Neurodiagnostics Laboratory*, was designed as a guide to objectively measure skin changes associated with long-duration EEG monitoring. 

Click here to download the F.L.E.S.H Scale.

*Used with permission of UF Health.

  1. ASET Position Statement: Skin Safety During EEG Procedures – A Guideline to Improving Outcome, Addendum: Neonatal Continuous EEG. approved by the ASET board of Trustees, November 16, 2016
  2. ASET Position Statement: Skin Safety During EEG Procedures – A Guideline to Improving Outcome, approved by the ASET board of Trustees, November 16, 2016
  3. Crawford, J. F.L.E.S.H. scale. University of Florida Health Neurodiagnostics Laboratory 2013
  4. Sheryl Nehamkin, R.EEG/EP T, CNIM, CLTM, FASET, University Hospitals of Cleveland, Rainbow Babies and Children's Hospital
  5. Petra N. Davidson, BS, R. EEG/EP T., FASET, Mayo Clinic Health System, Mankato, MN
  6. Saurabh R Sinha, Lucy Sullivan, Dragos Sabau, Daniel Sanjuan, Keith Dombrowski , Jonathan J Halford, Abeer Hani, Frank Drislane, Mark Stecker American Clinical Neurophysiology Society Guideline 1: Minimum Technical Requirements for Performing Clinical Electroencephalography, Copyright 2016 © American Clinical Neurophysiology Society
  7. 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.

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