Issues in Pediatric Wound Care

I wrote this inaugural column on pediatric wound care on the heels of an amazing conference: the 6th Meeting of the International Society of Pediatric Wound Care (ISPeW) held in Rome, Italy, this past November. I was privileged to share my work with and learn more about this very special group — the superheroes of pediatric wound care — of which I am a proud member. These clinicians, nurses, scientists, and industry supporters are dedicated to the mission, “To fight for what we believe in: save the children, care for skin and supporting tissues, prevent injuries, and let our babies grow without pain,” as proposed by the founding president of this society, Dr. Guido Ciprandi.

As I visited the Colosseum, Pantheon, and Tower of Pisa, ancient giants of human history, I couldn’t help but think of the connections among the past, present, and future of medicine. We live in an era rich with medical technologies. Advances in pediatric and neonatal care have transformed how we approach the challenges of caring for this population. Neonates the size of my palm now survive, only to encounter pressure injuries, skin tears, surgical wounds, congenital anomalies, and device-inflicted injuries. These same wounds affect older patients, in addition to trauma, burns, infections, congenital skin conditions, and medication-inflicted cutaneous damage. Although the trajectory of pediatric wound healing is the same as in adults, even faster and at times more efficient, practitioners who treat children still face obstacles — the biggest is recognizing that even though the pediatric population represents the majority of wounds and general wound management principles stand true across all ages, care and products have to change. The immaturity of neonatal skin, the child’s inability to communicate, medicinal systemic effects, pain infliction, and lack of size-appropriate products, not to mention parental angst and litigation risks, demand that we care according to evidence-based research recommendations. Pediatric wound care has largely been based on provider experience and preference and what is known about adult wound healing; rigorous research in neonatal and pediatric wound care often is lacking.

Pediatric wounds are common, they hurt, they disfigure, they prolong hospitalization, and more importantly, they often are inflicted by providers. Up to 27% of patients in intensive care experience pressure injuries. Up to 30% of children will develop an extravasation, 10% leading to significant wounds; 40% of hospitalized children have a surgical wound, 20% require complex care, and up to 5% of wounds may dehisce. Wounds inflicted as side effects of drugs may be worse than the condition they intend to treat. Diaper dermatitis affects up to 40% of neonates; some of the worst cases occur in oncology and chronic rehab patients. Burns are among the most common accidental injuries. Children with congenital genodermatoses face multiple daily challenges. The physical and emotional pain these children and their parents experience is not quantifiable.

As I marveled at the Roman Pantheon, a structure that has stood intact for more than 2000 years, I couldn’t help but wonder, How did they build it? The world’s largest unreinforced dome is a miracle of architecture, yet it was built without computers, sophisticated cranes, or lasers. I can only imagine the wounds inflicted on the workers. Yet, most treatments of the time were herbal, natural remedies. In line with that thinking, despite the amazing technologies that currently enrich our lives — from virtual reality, wearable data gadgets, immunotherapy, and genome-targeted therapies — we continue to recognize the importance of nontoxic care, antibiotic stewardship, and product compatibility. Honey, aloe vera, amniotic membranes, collagen, surfactant-based products, and good nutrition were discussed during the ISPeW meeting as well as at recent Symposium on Advanced Wound Care conferences.

My hope for this column is to bridge the new modalities that are shaping the future with what we have today and what worked in the past, to bring awareness to pediatric wounds, and to promote quality improvement in the pediatric wound arena by preventing and demonstrating increasing intolerance to hospital-acquired skin injuries by asking the right questions. One our many brave patients is pictured.