The Conference on Children With Wounds

The Seventh International Society of Pediatric Wound Care (ISPeW) meeting in Houston, TX, is history, but as usual, it made history. I feel empowered after exchanging ideas for 3 days with like-minded pediatric wound practitioners from all over the world; I feel hopeful and invigorated after interacting with multiple sponsors and leaders in the wound industry that recognize the need for pediatric-targeted, safe, and effective wound products.

For those unfamiliar with ISPeW, the Society was started by 3 visionary and dedicated colleagues in Rome, Italy — Dr. Guido Ciprandi, Dr. Marco Romanelli, and Dr. Corrado Maria Durante — after Italy witnessed a significant increase in the number of children admitted with wounds. Subsequently, the first Italian Wound Care Pediatric Surgical Center was created. 

The increase in pediatric wounds has been recognized throughout the world. Multiple multidisciplinary pediatric leaders with innovative ideas have come together to share the challenges of needing better practices, guidelines, products, and data. This group includes physicians, nurses, pharmacists, nurse practitioners, and physical therapists representing pediatric and fetal surgery, neonatology, plastic, burn, trauma and orthopedic surgery, dermatology, infectious diseases, pain and palliative care, basic researchers and engineers, industry leaders, and inventors, all united with a single aim: to improve pediatric wound care.

Many topics were covered during the ISPeW meeting. Here are several worth highlighting.

Negative pressure wound therapy (NPWT). A search of the literature will provide a decent number of publications addressing pediatric NPWT, including use of both canister models and portable, single-use, canisterless (sNPWT) units. Fewer articles have been published on NPWT use in the neonatal population; most are case reports, case series, and overview articles. 

The benefits of NPWT include faster healing; wound protection; incision stabilization; decreased edema; and granulation tissue production via microstrain and macrostrain that leads fibroblast stimulation, angiogenesis, lymph flow generation, exudate management, biofilm prevention, and drawing of wound edges together. Concerns regarding use of NPWT in very young patients stems from basic physiologic differences between children and adults and neonates and children. Skin is thinner and less developed in neonates; dressing application and removal can cause skin tears, epidermal stripping, dermatitis, and pain. Also, wound space is smaller in children, leading to difficulty in positioning/securement.¹ Clinicians must recognize the differences in mean arterial pressure in neonates, the risk for volume loss and hypotension due to small total blood volume, and easy compressibility of neonatal vessels due to diminished dermal/subcutaneous support. 

Recommendations for NPWT use in this population include starting with lower mm Hg (25 in preterm, 50 in term, and 80 in older children) and slowly increasing the setting, not to exceed 80 mm Hg. A continuous setting is recommended because intermittent NPWT is not well tolerated by children.^2-6 These conservative settings minimize the risk of underlying tissue trauma and fistula formation. The wound should be checked initially after 2 to 4 days; thereafter, the device may be left on for 7 days if possible to minimize skin stripping. 

Portable units are especially useful in pediatric and neonatal settings.^7,8 Many have a silicone sheet, leading to less trauma. Most NPWT devices can be left on for 7 days and others for up to a month. Most have a set pressure of 80 mm Hg, but the mechanism of action is not only negative pressure, but also fluid evaporation via the dressing, leading to excellent tolerance of this pressure. I have changed my practice to mostly sNPWT units secondary to ease of application, nonprofessional caregivers, and facilitation of earlier discharge and insurance coverage. I suggest using a liquid skin polymer before dressing/drape application and a silicone adhesive remover to facilitate pain- and trauma-less dressing changes.

Safe topical antimicrobial products. Biofilm-based skin and wound care has gained recognition in recent years. This approach emphasizes debridement to remove biofilm and prevention of its reformation or bacterial surface colonization. Traditional management in pediatrics has been to administer systemic antibiotics and topical antibiotic ointments; neither has been very successful in biofilm eradication or prevention of skin colonization. Traditional topical antimicrobials all have relied on bacterial cell death, invariably leading to systemic host reaction, exotoxins, and inflammatory cytokine release along with bacterial byproduct and endotoxin release. Immature or immunocompromised patients often are affected by this inflammatory cascade. 

Many topical antimicrobials are challenging in this population; silver and betadine can cause systemic toxicity, and no pediatric data exist for polyhexamethylene biguanide or methylene blue. Hydrophobic technology (via dialkylcarbamoyl chloride coating) can support host control of the skin/wound environment by passively removing microbes through hydrophobic microbe binding, leading to bacterial inactivation, quiescence, and a decreased systemic reaction of the host.^9,10 This unique technology also can work as a preventive measure in the at-risk, vulnerable population undergoing skin manipulation. 

In addition, a hydrophobic dressing placed proactively on high-risk incisions or denuded skin will provide a binding surface for microbes, eliminating skin colonization. This technology was highlighted during the meeting as a gentle yet effective antimicrobial choice for wounds of many etiologies, including pressure injuries, genodermatoses, surgical wounds, dermatitis, abscess, reconstruction and graft areas, and over incisions in high-risk population.

Device-related pressure injuries (PIs). Professor Amit Gefen enlightened attendees about the  etiology of PI. As such, the soon-to-be-released 2019 International Consensus Statement will highlight deformation of cells and tissues and subsequent cellular injury as the principle cause of device-related pressure injuries. Ischemia, necrosis, and apoptosis are sequalae to the original cell injury secondary to deformation, organelle damage, and cellular leak. 

More than 50% of pediatric PIs are device-related; understanding the concept of deformation and the surrounding microclimate should change the way we practice medicine. Deformation can be avoided if devices are offloaded, underscoring the emphasis on preventive actions and not “after-the-fact” treatment.¹¹ Microclimate generated by temperature, humidity, and moisture will increase skin susceptibility to injury; using absorptive dressings can minimize the effects. 

Assessment scales. We know pediatrics represents a unique challenge in terms of available skin assessment scales. Until recently, none had taken devices into account. One of the highlights of the meeting for me was listening to a dynamic trio of Braden QD developers (Sandy Quigley, RN, MSN; Judith Stellar, RN, MSN; and Catherine Noonan Caillouette, RN, MSN) describing their journey of scale development, the addition of a device parameter, and their suggestions for implementing the new scale.^12,13 I look forward to determining whether this scale will improve caregiver ability to accurately predict who will actually develop PI.

The role of child life specialists in wound management/office child-friendly environment. More and more, we speak not just about survival, but also about morbidities, future challenges, and the pain and suffering encountered along the journey in the hospital ward or a short clinic visit. Quality of care, satisfaction, partnership, and comfort resonate as goals more than ever before. In the neonatal intensive care unit (NICU), we talk about neurodevelopmentally appropriate care, providing a soothing environment, partnering with parents, and decreasing painful stimuli because pain and anxiety have been proven to have long-term deleterious effects. 

In my hospital, we utilize the help of child life specialists while rounding, administering medication, performing procedures, and, in older children, preparing for procedures and tests and sharing difficult information. In the NICU, these specialists partner with occupational therapists to provide developmentally appropriate touch, positioning, and comfort while I perform debridement; they teach parents how to soothe the baby after a procedure and they become a liaison between a provider and nurses or families. On the pediatric floors they support children using toys, technology, music, singing, hand-holding, and talking. 

We also utilize a pain team and clergy to help us deliver better care. I know pediatric providers realize the importance of distraction and a kid-friendly environment no matter what procedure needs to be done and the crucial effects of neurodevelopmental support of the preterm neonate. The conference included a great discussion about making our offices peds-friendly: art on the walls and ceiling, toys in the room, comfortable equipment for parents to hold their children, warm temperature, and supportive staff.

Use of telemedicine for transition of care in NICU patients with wounds and the role of a community wound, ostomy, continence (WOC) nurse in caring for complex pediatric patients. Practitioners treating patients who do not live near health care facilities face this complex issue every day. Not every patient can access a large academic center, not every patient has necessary resources within driving distance, not many home agencies have nurses comfortable taking care of complex patient or patients with wounds, and not many rehabilitation facilities have practitioners knowledgeable in wound care. A model originating in the Boston Children’s NICU was presented where the team of neonatologists, WOC nurses, and specially trained nurses partner with community pediatricians, nurses, long-term care providers, and home nurses in order to educate them and guide patient care out in the community. This model provides better care, fewer readmissions, reduced cost for the hospital, and, most importantly, safer and expedited discharge. Although this is not an easy undertaking, I believe this is one way future care can be extended to difficult-to-reach geographic areas or to simply provide a good night sleep for a worried parent.

Additional topics. More laudable ISPeW topics included working with families as partners in pediatric wound care, the value of early occupational therapy in NICU wound care, use of nitrous gas for effective management of pain and anxiety in pediatric wound care office procedures, fragile wounds in facial wounds combined with capillary malformation and arteriovenous malformation, wounds in congenital abdominal wall defects, concentrated surfactant technology, amniotic skin substitutes in pediatric care, and polymeric membrane dressings. I hope you can appreciate the ongoing growth and transformation in the field of pediatric wound care. I plan to zero in on many of these topics next year. 

I invite you to the upcoming eighth ISPeW meeting to be held in conjunction with World Union of Wound Healing Societies in Abu Dhabi, United Arab Emirates, March 8 through 12, 2020. I wish every one a happy and healthy 2020!