Shifting From Adult to Pediatric Wound Care

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After almost 3 decades of working in adult wound care, I ventured into the pediatric setting. My adult wound care colleagues often asked me “What are the differences between adult and pediatric wound care? What types of wounds do you see now? What products are safe to use in neonates?

The first thing a pediatric wound care person will tell you is that “Children are not small adults. Pediatric wound care is its own subspecialty.” However, because research in pediatric wound care is limited, adult protocols and research findings are utilized with modifications made for the pediatric population.^1,2

The biggest differences in the pediatric population are safety considerations for gestational and neurodevelopmental age, common wound types, and attention to pain management.

The golden rule of “Above all do no harm” has increased consequences in pediatrics, especially in low birthweight and premature infants. Pediatric ages range from prenatal to 21 years with weights ranging from as small as 500 grams (approximately 1.5 pounds) to over 500 pounds. Weights are recorded in kilograms.   

The principles of wound care are the same for all ages: Treat the underlying problem, prevent and treat infection, suppress inflammation, debride devitalized tissue, promote a moist wound healing environment, protect the periwound and optimize nutrition. Here are some observations I have made in the last 6 years comparing adult to pediatric wound care.

Safety Considerations for the Neonate

To understand acceptable treatment interventions for skin/wound conditions, one must evaluate weeks of gestation (time between conception and birth). A full-term pregnancy is 37–40 weeks. Pre-term is before 37 weeks and extreme pre-term is less than 28 weeks. A full-term infant has the barrier structure but not the function of an adult. The stratum corneum is approximately 30% thinner.

The extremely premature infant has almost no stratum corneum—the skin is translucent and gelatinous in appearance and the dermal-epidermal bond is very weak.^2,3 These infants are therefore prone to epidermal stripping from adhesive removal, friction injuries and blistering, and marked fluid loss. They are at extreme risk of toxic systemic levels of chemicals absorbed through the skin. This increased toxicity, compared to that of an adult, is due to immature hepatic, renal, and central nervous systems that cannot metabolize and excrete chemicals efficiently. Absorption of common disinfectants such as povidone-iodine, chlorhexidine and alcohol may result in hypothyroidism, encephalopathy, and skin necrosis respectfully.² It is best practice to evaluate each product for efficacy and toxicity potential and remove as completely as possible with sterile water or saline after any procedure.

Common Wound Types Seen in Pediatric Wound Care

Pressure injuries, incontinence associated dermatitis (IAD), accidental injuries (motor vehicle accidents and burns), moisture associated skin damage (MASD), intravenous extravasations, abscesses, atopic dermatitis, and medical adhesive–related skin injuries (MARSI) are some of the most common wound types seen in pediatrics. Genetic and congenital conditions such as epidermolysis bullosa, abdominal wall defects, and ichthyosis are rare but seen uniquely in pediatrics.⁴  

Pressure injuries. As in adults, significant limited mobility, loss of sensation, nutritional deficits and cognitive impairment are reasons for the development of pressure injuries in children. Differences include body composition, common locations, and percentage of medical device related injuries. From birth to age 6, the primary site of breakdown is the occiput due to relative head size for the body.⁴ As body proportions even out, the most common locations are the same as in adults—sacrum and heels. Medical devices, especially respiratory devices, account for more than 50% of all pediatric pressure injuries. Breakdown often occurs in areas without adipose tissue and in patients with craniofacial anomalies due to facemasks.^1,5,6

Patients prone to pressure injuries within the pediatric population include infants and complex care kids (those with cerebral palsy and neurodevelopmental delays). They have a higher fat percentage and lower lean body mass compared to adults. This makes their subcutaneous tissue softer and susceptible to deformation under the same force.⁶

Abscess management. The vessel loop technique is the standard of care in abscess management in pediatrics. This technique is very successful in keeping the site open, allowing for continual drainage and eliminating dressing change trauma, which is painful for any age.⁷ I don’t miss the days of trying to pack a ¼-inch packing strip into a slit so small the stick end of the cotton tip applicator had to used.

Incontinence-associated dermatitis. This occurs in both the pediatric and adult population, but incontinence associated with dermatitis is a common occurrence in pediatrics.² Evidence shows that barrier creams may be beneficial in both prevention and treatment but do not provide a substitute for frequency of diaper change and use of superabsorbent diapers. Similar to the adult population, treatments include various zinc oxide, petrolatum and dimethicone based ointments as well as cyanoacrylates. Differences in pediatrics include attention to alleviate the cause and decrease friction and irritation. Care includes use of soft non-sterile cloths and alcohol- and preservative-free wipes, and spray on ointments and barriers. Allowing “air time” is also a great treatment strategy.^2,8   

Ulcerations. While arterial, venous, and neuropathic ulcerations account for a majority of adult lower extremity wounds, accidental trauma (pedestrian, bicycle, and motor vehicle accidents) is the number one reason for lower extremity wounds in children.¹¹ Vascular anomalies and complex skin problems may also lead to open wounds in children. 

Extravasation injuries (inadvertent leakage of a vesicant). These are more common in the pediatric population due to decreased vein caliber and fragility and patient movement. Prevention and treatment focuses on the need for the line, continual assessment of the site and treatment of any devitalized tissue. Plastic surgery is consulted on all full-thickness skin loss to protect against disfigurement and loss of limb function.²

Selecting a Wound Dressing for Pediatric Patients

Dressing selection in pediatrics focuses on avoiding aggressive adhesives and reducing frequency of dressing change. Choices are the same as in adults and include transparent films, hydrocolloids, hydrogels, foams, alginates, hydrofibers, medical grade honey, collagen, methylene blue, hydroconductive, and polymeric membrane dressings.

Iodine-containing dressings are largely avoided in the pediatric setting due to safety concerns for thyroid toxicity. Silicone products are favored due to ease of removal and prevention of MARSI. Medical grade honey is highly utilized for autolytic debridement and promotion of an antimicrobial environment. Silver products are generally considered safe although no pediatric prospective studies related to absorption are available.⁹ Case studies indicate safe outcomes as long as long as normal renal function is present, especially in the neonate.

Adjustments for Patient Size

Specialty beds. Small children simply do not line up correctly in adult designed specialty beds (low air loss, air fluidized). Anyone weighing under 22 kg. (70 lbs.) risks entrapment by sinking into and between the cushions.¹⁰ Pediatric specific low air loss beds, designed for weights 1.6 lbs., up to 100 pounds, are now available. It is important that the proper weight-based specialty bed be utilized.

Heel boots. While wonderful for offloading heel pressure and providing prevention of plantarflexion contracture, kids find heel boots hot and often kick them off just as adults do. Boots are not made in a pediatric specific size but do come in a small or geriatric size and can used on most school age children.  

Negative pressure wound therapy (NPWT). Adult use of NPWT has been reported since 1996 and pediatric use since 2006. Limited research in pediatrics is available but numerous case studies confirm its benefits and safety.¹¹ Pediatric pressure settings range from 25–125 mmHg, depending on age and diagnosis. In neonates, most studies demonstrate that 25–50 mmHg setting is sufficient to reduce the risk of fluid loss and hemodynamic instability. A good rule of thumb is to keep the pressure setting below the mean arterial pressure which is approximately equal to the child’s gestational age. A 40-week gestation neonate, therefore, should have a mean arterial pressure of 40 mm. To ensure safety, the pressure setting should not be more than 25 mmHg.¹²

A contact layer or liner under the vacuum sponge is utilized more often in pediatrics to facilitate prevention of granulation into the sponge and easier dressing removal.¹¹  

Pain management. In my experience with adult patients, we utilized the music and scenery television offerings and were certain to provide IV or oral pain medication as needed. In pediatrics, however, there is an increased pain management focus, which begins with an appropriate neurodevelopmental assessment. Behavioral characteristics such as facial expressions, restlessness, anxiety, and increase in vital signs bring adjustments to the wound care plan. Many more procedures are done in the OR due to pain concerns.

The use of distraction techniques is taken to the next level in pediatrics and really works! Playing a child’s favorite music or video, including family members (in person or over video), and waiting for any pre-medication to take effect are a few very useful techniques. Child life specialists are especially helpful in engaging the child and offering distraction strategies. They have specialized training and a gifted sense of just what will relax and refocus a child.  

When adhesives are applied, a silicone adhesive remover spray (called the magic spray) is utilized generously and frequently. This increases trust and facilitates much easier removal of any topical dressing. Other pain management techniques include sucrose for infants and the use of warmed saline irrigation to assist with dressing removal. Securement devices such as stretchy tubular net gauze work well to secure the dressing without adding any adhesives.

Figure 1. Neonate with NPWT (suction set to 25 mmHg).

Figure 2. Neonate with necrotizing enterocolitis and a dehisced surgical incision.

Figure 3. Neonate with Strattice graft.

Figure 4. Primary cutaneous Aspergillosis in a 23-week neonate.

Figure 5. A neonate with a healed incision.

In Conclusion

Children are certainly not small adults. Adjustments to any adult wound care protocols are made with care and concern. However, much of adult and pediatric wound care is the same. We face similar challenges when treating difficult to heal wounds, especially in our most vulnerable patients. A wound is a wound and a centimeter is a centimeter, whether it is being measured in an 8-month-old or an 80-year-old. We see the full circle of life when we witness epidermal thinning, little to no subcutaneous tissue and translucent skin in the elderly. We can work together to find solutions to common problems. We can all take the time to manage pain, and provide the best available treatments.
 
MaryAnne Lewis is the community wound ostomy continence (WOC) nurse for Texas Children’s Hospital. She has 40 years of nursing experience, 34 of those dedicated to wound, ostomy and continence care. While a majority of her WOC nurse experience has been in the adult sector, the last 6 years have been dedicated to the pediatric population. She is board certified in all 3 subspecialties and served as President of the South Central Region of the Wound Ostomy and Continence Nurses Society from 2020–2023. Lewis recently co-authored a chapter in an international book, Neonatal and Pediatric Wound Care. Among her professional honors, Lewis has received the Good Samaritan Foundation Excellence in Nursing bronze award and has been recognized for “Outstanding Performance in Nursing” by the Texas Nurses Association district 9.

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References
1. 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. doi: 10.1097/01.ASW.0000266646.43159.99. PMID: 17415029.
2. Lund C, Singh C. Skin and wound care for neonatal and pediatric populations. In McNichol LL, Ratliff C, Yates S (eds.). Wound Ostomy, and Continence Nurses Society Core Curriculum Wound Management, 2nd ed., 2022, pp. 243-245. Phil, Wolters Kluwer.
3. Association of Women’s Health, Obstetric and Neonatal Nurses (AWOHNN). Evidence Based Clinical Practice Guideline: Neonatal Skin Care, 4th ed., 2018. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses.
4. Stellar J, Vanzi V. Advanced dressings in pediatric wound care. In Ciprani G (ed.) Neonatal and Pediatric Wound Care, 2021, pp.236-262. Edizioni Minerva Medica.
5. European Pressure Ulcer Advisory Panel, National Pressure Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries; Quick Reference Guide. Emily Haesler (Ed). EPUAP/NPIAP/PPPIA: 2019
6. Freundlich K. Pressure Injuries in Medically Complex Children: A Review. Children (Basel). 2017 Apr 7;4(4):25. doi: 10.3390/children4040025. PMID: 28387749; PMCID: PMC5406684.
7. Gottlieb M, Peksa GD. Comparison of the loop technique with incision and drainage for soft tissue abscesses: a systematic review and meta-analysis. Am J Emerg Med. 2018; 36(1):128-133. doi:10.1016/j.ajem.2017.09.007
8. McNichol LL, Ayello EA, Phearman LA, Pezzella PA, Culver EA. Incontinence-associated dermatitis: state of the science and knowledge translation. Adv Skin Wound Care. 2018 Nov;31(11):502-513. doi: 10.1097/01.ASW.0000546234.12260.61. PMID: 30303813.
9. King A, Stellar JJ, Blevins A, Shah KN. Dressings and products in pediatric wound care. Adv Wound Care (New Rochelle). 2014; 3(4):324-334. doi:10.1089/wound.2013.0477
10. McLane KM, Krouskop TA, McCord S, Fraley JK. Comparison of interface pressures in the pediatric population among various support surfaces. J Wound Ostomy Continence Nurs. 2002 Sep;29(5):242-51. doi: 10.1067/mjw.2002.127208. PMID: 12510470.
11. McCord MS, Ciprani, G, Lewis, MA, Crucianelli S. Negative pressure wound therapy in infants and children. In Ciprani G (ed.). Neonatal and Pediatric Wound Care, 2021, pp.263-280. Edizioni Minerva Medica.
12. Steen EH, Wang X, Boochoon KS, et al. Wound healing and wound care in neonates: current therapies and novel options. Adv Skin Wound Care. 2020 Jun;33(6):294-300. doi: 10.1097/01.ASW.0000661804.09496.8c. PMID: 32427785.
13. McCord S, Levy M. Practical guide to pediatric wound care. Semin Plast Surg. 2006; 20(3):192-199.