Journal of Perinatology (2014) 34, 161163

& 2014 Nature America, Inc. All rights reserved 0743-8346/14

www.nature.com/jp

PERINATAL/NEONATAL CASE PRESENTATION

Clinical experience with Leptospermum honey use for treatment of
hard to heal neonatal wounds: case series
V Boyar1,2, D Handa1, K Clemens3 and D Shimborske3

Preterm, critically ill neonates represent a challenge in wound healing. Many factors predispose infants to skin injuries, including
decreased epidermaldermal cohesion, decient 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 honeyLeptospermum
honey (Medihoney), for successful treatment of slowly healing neonatal wounds, specically stage 3 pressure ulcer, dehiscent and
infected sternal wound, and full-thickness wound from an extravasation injury.

Journal of Perinatology (2014) 34, 161163; doi:10.1038/jp.2013.158

Keywords: Medihoney gel; prematurity; skin breakdown; wound healing; wound dehiscence

INTRODUCTION treatment, a right leg stage 3 pressure ulcer was noted in the
There is an increased awareness that premature babies and lower right calf (Figure 1a). His initial treatment involved
neonates born with congenital defects are at increased risk for application of hydrogel covered by a hydrocolloid dressing. After
skin breakdown. Many factors predispose neonates to skin injuries, two weeks of such treatment and minimal improvement,
including decreased epidermaldermal cohesion, decient stra- Medihoney gel, covered with Medihoney infused hydrocolloid
tum corneum, more alkaline pH of skin surface, poor nutrition, (MHCS) and an outer dressing was initiated. Medihoney gel
relatively immature immune system and large areas exposed to was applied every three days for the rst two weeks. By the
equipment. As technology brings cure, it also brings risk factors, end of the second week substantial granulation and new
such as adhesives that strip epidermal layers, catheters that epithelialization was noted. The dressing application was changed
increase risk for extravasations and devices that place pressure to once a week, and by the end of the fourth week the wound was
and friction stress on vulnerable skin. closed, with increasing natural pigment distribution and soft scar
In our experience, hydrogel covered with hydrocolloid or (Figure 1b).
silicone dressing is often sufcient to heal neonatal skin break-
down, but occasionally stalled or difcult-to-treat wounds present
Case 2. Dehisced and infected surgical wound
a diagnostic challenge. Recently medical honey gained attention
in the adult community as a treatment for various dermatologic Three-month old, former 36-week gestation female was born with
conditions. We introduce a new approach (for the neonatal a diagnosis of hypoplastic left heart syndrome, double outlet right
community) to treatment of various neonatal skin breakdowns ventricle, unbalanced AV canal and partial trisomy 16. Following
using active Leptospermum honey, a medical-grade honey the rst stage Norwood repair and Sano shunt placement at two
(Medihoney Derma Sciences, Princeton, NJ, USA), the only honey weeks of age, she developed a sternal wound dehiscence and
cleared by FDA for treatment of various dermatologic conditions secondary bacterial infection. The wound measured 2  11 cm
in adults. There are no known contraindications for pediatric or with slough, exudate and sternum exposure. Initially hydrogel
neonatal use, other than allergy to honey. We present three covered by silicone dressing was used without success. After 10
successfully treated cases, including stage 3 pressure ulcer, days, continuous negative pressure wound therapy at 50 mm Hg
dehiscent and infected sternal wound, and extravasation-related was started. Minimal slough removal and few new granulation
full-thickness wound. 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 improve-
CASE ment was seen in the rst week and the wound had completely
Case 1. Stage 3 pressure ulcer healed by week three (Figure 2b).
Three-month old, former 28-week gestation male born with
double outlet right ventricle, VSD and right ventricular outow
tract obstruction. On DOL#80, he was taken to the catheterization Case 3. Full-thickness wound from extravasation injury
lab for ballooning of the pulmonary valve. After the procedure he Three-week old former 26-week female was born due to preterm
experienced decreased pulses on the right lower extremity with labor and maternal sickle cell disease crisis. At three weeks of age,
delayed capillary rell. Treatment included low-dose heparin, a stage 4 right ankle peripheral IV extravasation injury was found.
followed by low molecular weight heparin. Two weeks into this For the rst 24 h it presented as a large, uid-lled bulla. The bulla
1
Division of Neonatal-Perinatal Medicine, Department of Pediatrics, New Hyde Park, NY, USA; 2Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA and 3Department
of Nursing Cohen Childrens Medical Center of New York, New Hyde Park, NY, USA. Correspondence: Dr V Boyar, Department of Pediatrics/Neonatology, Steven & Alexandra
Cohen Childrens Medical Center of NY, North Shore LIJ System, 269-01 76 Ave, New Hyde Park, NY 11040, USA
Received 28 June 2013; revised 22 October 2013; accepted 23 October 2013
 Clinical experience with Leptospermum honey in neonatal wound healing
V Boyar et al
162

Figure 2. (a) Sternal wound after 2 weeks of negative pressure

Figure 1. (a) Stage 3 pressure ulcer: minimal healing after 2 weeks of therapy and 2 weeks of hydrogel/silicone dressing combination:
hydrogel and silicone dressing. (b) At the end of 4 weeks with Slough present. Sternal bone is visible. (b) Week 3 with Medihoney
Medihoney: note pigmented epidermis. gel and MHCS: complete healing. MHCS, Medihoney infused
hydrocolloid.

ruptured the following day and evolved into full-thickness wound, saliva and nectar. We know that honey is about 20% water and
with areas of slough and exudate. Medihoney gel was started on 80% sugar, with certain enzymes added by the bees.8 Medihoney
day 2, covered by a hydrocolloid dressing. It was reapplied every 3 Antibacterial Wound gel consists of 80% Leptospermum honey,
days for the rst 10 days. New granulation tissue and decrease in 15% Myristyl Myristate and 5% Plantacare (natural vegetable
exudate were noted by day 6. Less discomfort with motion and derived esters for emulsication and stability). Leptospermum
less periwound edema was noted as well. After 10 days dressing honey is known to possess specic properties that make it an ideal
was changed once weekly, and by 3 weeks the wound had healed therapeutic agent. It possesses antimicrobial activity due to its
with full range of motion and soft pink scar. high osmolality (high sugar content) which suppresses bacterial
growth. One of the enzymes added, glucose oxidase, converts
glucose to gluconic acid, making the honeys pH (3.5 to 3.9) too
DISCUSSION acidic for bacteria.79 Bees add natural hydrogen peroxide to the
Preterm neonates represent a unique group of patients as their honey and naturally occurring phytochemicals also are thought to
immature skin, compromised perfusion, limited mobility, sub- be antibacterial. Honey decreases natural biolm formation. It has
optimal nutritional status and need for multiple devices may lead an anti-inammatory activity because the high osmolality of the
to slow wound healing. Treatment for pressure ulcers, extravasa- honey draws water out of the wound and reduces edema. Lastly, it
tion injuries and dehisced wounds often involves application of is autolytic because it creates moist environment that enhances
hydrogel/hydrober, covered by ether hydrocolloid or silicone autolysis; increasing lymph uid that delivers plasminogen.
dressing. The aim is to ll dead space, maintain moist wound Plasminogen is converted to plasmin thereby increasing degra-
environment, induce new epithelial tissue growth and protect the dation of brin strands in the slough. Medihoney undergoes
wound from infection and trauma. Stage 1 and 2 pressure ulcers gamma irradiation to inactivate any microorganisms that may be
or partial thickness wounds should show evidence of healing present, such as Clostridial spores.10
within 1 to 2 weeks, while stage 3 and 4 ulcers/full-thickness During our case series, we dealt with very compromised,
wounds should show evidence of healing within 2 to 4 weeks.13 critically ill preterm babies. Medihoney products demonstrated
Specically for ulcers it has been demonstrated that healing less ease of use, decreased pain with dressing changes, timely wound
than 0.1 cm per week predicts high risk for non-healing at 6 closure and no side effects in our patients. For these reasons,
months.4 There are various reasons for poor healing, including Medihoney was added to our formulary. Recently, we started
impaired perfusion and oxygenation, non-resolved inammation, using honey products as a rst-line therapy for stage 2 and higher
presence of proteases and recurrent physical trauma. pressure ulcers, extensive extravasation injuries and open surgical
The use of medical-grade honey in wound healing has been wounds. Time to closure seems superior to previous practice
traced many centuries back to Medieval Europe and ancient (hydrogel plus secondary dressing). This may translate to cost
Egypt. The unique properties of medical honey explain its ability advantages. We recommend considering medical-grade honey
to treat various types of skin injuries.57 Honey is a mixture of bee when faced with difcult-to-treat neonatal/pediatric wounds.

Journal of Perinatology (2014), 161 163 & 2014 Nature America, Inc.
 Clinical experience with Leptospermum honey in neonatal wound healing
V Boyar et al
163
CONFLICT OF INTEREST 5 Acton C, Dunwoody G. Honey: where should it be placed on the wound care
The authors declare no conict of interest. formulary? Proceedings of the European Wound Management Association
Conference: Lisbon, Portugal, 2008, Poster.
6 Acton C. Medihoney: a complete wound bed preparation product. Br J Nurs 2008;
17(11): S44S48.
REFERENCES 7 Molan PC. Re-introducing honey in the management of wounds and ulcers-theory
1 Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999; 341(10): 738746. and practice. Ostomy Wound Manage 2002; 48(1): 2840.
2 Flanagan M. Improving accuracy of wound measurement in clinical practice. 8 Molan PC. Mode of Action. In: White RJ, Cooper RA (eds). Honey: A Modern Wound
Ostomy Wound Manage 2003; 49(10): 2840. Management Product. Wounds, 2005; UK, Aberdeen.
3 Bergstrom N, Altman R, Alvarez O, Bennett A, Carson C, Frantz R et al. Treatment of 9 Gethin G, Cowman S, Conroy R. The impact of Manuka honey
Pressure Ulcers. Clinical Practice Guideline, Number 15. AHCPR Publication no.95- dressings on the surface pH of chronic wounds. Int Wound J 2008; 5(2):
0652. Rockville, Md.: Agency for Health Care Policy and Research, Public Health 185194.
Service, U.S. Department of Health and Human Services 1994; 12. 10 Yoon YM, Newlands C. Quality standards of medical grade Manuka honey. In:
4 Bell AL, Cavorai J. Noncontact ultrasound therapy for adjunctive treatment of White RJ, Cooper RA (eds). Honey: A Modern Wound Management Product.
nonhealing wounds: retrospective analysis. Phys Ther 2008; 68: 15171524. Wounds, 2005; UK, Aberdeen.

& 2014 Nature America, Inc. Journal of Perinatology (2014), 161 163