Abstract: BackgroundNeonates admitted to the neonatal intensive care unit (NICU) are at high risk of iatrogenic skin injury. However, no established risk prediction models are currently available. ObjectiveTo identify risk factors associated with iatrogenic skin injury in NICU neonates, construct a nomogram-based risk prediction model, and validate its performance. DesignCase-control study. MethodsNeonates born at Nanfang Hospital, Southern Medical University, and admitted to the NICU between January 2020 and December 2023 for ≥24 hours within 28 days of birth were included. Exclusion criteria were pre-existing skin damage or infection before NICU admission, congenital skin diseases or conditions predisposing to skin injury (e.g., teratomas), post-surgical status, transfer to another hospital, or discharge against medical advice. Based on the presence or absence of iatrogenic skin injury recorded in medical records, neonates were categorized into the injury group and non-injury group. Risk factors were determined through literature review and two rounds of Delphi expert consultation. Data on neonatal demographics, clinical characteristics, and perinatal maternal factors were retrospectively collected from the medical record system. Univariate and multivariate analyses were conducted to identify independent risk factors, which were used to develop a predictive model and externally validate it. Main outcome measuresPredictive performance of the risk model for iatrogenic skin injury in NICU neonates. ResultsA total of 631 neonates were included in the analysis, with 170 cases (26.9%) in the injury group and 461 cases in the non-injury group. The modeling cohort included 442 neonates, while the validation cohort comprised 189 neonates. There was no significant difference in baseline characteristics between the modeling and validation groups. Univariate and multivariate analyses identified the following independent risk factors for iatrogenic skin injury: gestational age at birth, birth weight, non-exclusive breastfeeding, use of paper-based medical adhesive tape, improper use of medical adhesives, removal of adhesives with 75% ethanol solution, use of non-invasive mechanical ventilation, use of restraint bands, and drug extravasation. The area under the ROC curve (AUC) for the prediction model was 0.929 (95%CI: 0.900-0.958) in the modeling cohort and 0.941 (95%CI: 0.908-0.974) in the validation cohort. The Hosmer-Lemeshow goodness-of-fit test yielded χ2 values of 14.649 (P=0.066) and 8.670 (P=0.371) for the modeling and validation groups, respectively, indicating good calibration. The clinical decision curve analysis demonstrated that early intervention for high-risk neonates based on the model could benefit most patients, suggesting high clinical applicability. ConclusionThe incidence of iatrogenic skin injury in NICU neonates is relatively high and is influenced by multiple factors. The developed prediction model demonstrates high clinical applicability and may help guide early preventive interventions.

Key words: NICU, Iatrogenic skin injuries, Risk factor, Nomogram, Early Intervention