Concentrated Surfactant Gel Dressing for Effective Wound Healing in Pediatric Patients: A Case Series

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Wound Management & Prevention or HMP Global, their employees, and affiliates.

Wound healing is a complex and highly regulated process requiring an intricate interplay between various factors to restore injured skin towards repaired barrier function.¹ Acute wounds heal in a well-organized timely fashion and include burns, traumatic injuries, and surgically created wounds. Chronic wounds do not follow wound healing in a timely and orderly manner as seen in acute wounds; they exhibit prolonged or excessive inflammation and may be more susceptible to persistent infections, formation of biofilms, and inability of the dermal or epidermal cells to respond to reparative stimuli.² There are national and international guidelines for chronic wound care; however, fewer guidelines for wounds with acute etiology are available.^3-6 In spite of these differences, both chronic and acute wounds are often treated based on the principles represented in the acronyms TIME or DIME (Tissue or Debridement, Inflammation, Moisture, Edge).⁷

It is important to understand that even though fundamentals of wound care in neonatal and pediatric patients are similar to those of adults, the specific wound practices may be different in pediatric versus adult patients.^8,9 There are age-related factors and physiologic and anatomical considerations that can impact wound care in pediatric patients and especially in the neonatal population, such as an underdeveloped epidermal barrier and an immature immune system that poses an increased risk of infection.^10-14 Concerns for systemic absorption of certain topical products and a suboptimal nutrition status predisposing the patient to slower healing are also factors.

In pediatric patients, a safe, nontoxic treatment strategy—both systemically and locally—must be emphasized. The choice of a dressing or product is based on its ability to provide a moist environment, promote wound healing, support slough removal, and minimize bacterial colonization and ongoing injury to cells while offering painless removal and ease of application. Other considerations include cost, product availability, frequency of dressing changes, and provider's familiarity with various wound dressings.^15,16

The author aims to show in this retrospective case series involving 8 pediatric patients (neonates and infants) with acute wounds that a CSG-based wound dressing (PluroGel Burn and Wound dressing, Medline Industries, Inc.) could create conditions conducive to wound healing and minimize pain during dressing changes.

The literature contains reports on the use of CSG dressings in both acute and chronic wounds, including ulcers and surgical incisions, partial- and full-thickness wounds, and first- and second-degree burns. Overall, wound healing outcomes have been favorable, with minimal pain during dressing changes and an established safety profile. The product creates an optimal moist wound healing environment, softens wound debris, and promotes autolytic debridement.^17,18 Therefore, the author used this dressing on young pediatric patients who had suffered acute wounds of various etiologies.

Each wound was assessed upon presentation at the author's hospital from March 2019 to January 2020. The CSG was chosen as both initial treatment on acute wounds as well as a treatment choice after other therapies failed. It was applied directly on the wound bed at a thickness of 2 to 3 mm either once or twice a day. Following the application of CSG, a secondary occlusive dressing was applied to maintain a safe, moist environment. A nonadherent pad dressing or perforated contact layer was often used as an interface between the CSG and a secondary dressing; silicone dressings were also used for smaller wounds, whereas thin, absorptive foam dressings were sometimes used to cover larger, irregular areas of the wounds. In addition to application of CSG, wounds were managed according to the hospital's protocols. NIPS was used for pain documentation.¹⁹ This score captures facial expression, cry, breathing pattern, and state of arousal in nonverbal children with a score of 0 or 1 assigned in each category; a total score of greater than 3 indicates pain or discomfort. A detailed description of each case management is given for each individual case study. Patient demographics, wound type, and treatment characteristics are shown in the Table. Consent for image and data use for educational publication was obtained from all guardians.

Case 1: severe peripheral intravenous extravasation injury

An 8-day-old male (26-week gestation, weight 900 g) receiving peripheral parenteral nutrition via PIV catheter sustained an extravasation injury on the left hand that resulted in significant swelling and multiple blisters. Hyaluronic acid was administered per hospital protocol. This was regarded as day 1 of treatment for this patient. Large blisters were punctured, without de-roofing, to allow drainage while providing natural covering for the wounded area. Wound was covered by a protective, atraumatic silicone dressing (Mepilex Border, Mölnlycke). On day 3, necrotic tissue on the wound bed was noticed, and removal by conservative sharp debridement was undertaken. The CSG dressing was then applied to provide a moist wound healing environment, prevent biofilm formation, and minimize inflammation. The wound bed was covered with a nonadherent pad dressing (Telfa, Covidien) and the atraumatic silicone dressing (Mepilex Border). The CSG was reapplied once per shift (approximately every 12 hours) as a thin, 3-mm layer to facilitate autolytic debridement, requiring minimal force or amount of scrubbing. Assessments given by bedside nurses using the NIPS indicated no pain (scores of 1 or 2) with the exception of a one-time score of 3 (mild pain). On day 6, the wound was contracting, but 50% of the wound bed was covered by a thin exudate. Mechanical debridement with a microfilament pad (Debrisoft, Lohmann & Rauscher, Inc.) was utilized to remove the loose exudate. As the wound bed continued to get smaller, dressing changes were spaced to once every 2 days. The wound bed was completely epithelized by day 15. The wound healing pattern can be seen in Figure 1.

Case 2: chemical burn and medical adhesive-related skin injury

A 4-day-old female (24-week gestation) was transferred to the author's hospital with a chlorhexidine-induced chemical burn that was exacerbated by epidermal stripping during a hydrocolloid dressing removal in an outlying hospital. The baby was transferred 4 days after initial presentation upon request of her parents. On admission, the partial-thickness wound measured 6 cm × 5 cm with hemorrhagic dried exudate covering 90% of the wound. The CSG dressing was initiated in this visit and was reapplied twice a day. The wound was covered with a perforated silicone dressing (Mepitel, Mölnlycke) and soft foam dressing (Mepilex Lite, Mölnlycke). On the following day, exudate appeared softened and was almost completely removed with gentle normal saline irrigation. The CSG dressing was applied once a day thereafter. Assessment using NIPS indicated no pain (scores of 1 to 2) during both CSG application and dressing removal. The wound healed within 8 days after initiating treatment with CSG without any scar formation or skin depigmentation.

Case 3: epidermal stripping

A 3-day-old female (34-week gestation) delivered at an outlying hospital was transferred to the author's hospital following an initial assessment that identified congenital heart disease. Upon arrival, 3 partial-thickness wounds were noted on her chest and abdomen area. The etiology of the wounds was deemed as epidermal stripping due to incorrect removal of electrocardiogram lead adhesive at the hospital where she was born. Treatment with CSG was initiated soon after her arrival and was regarded as day 1 of treatment. The CSG was applied twice a day and was covered with a silicone dressing (Mepilex, Mölnlycke). The CSG was effective at keeping the wound bed moist and free of slough. It also supported granulation and eventual epithelization. Her wounds healed within 7 days. Reported NIPS scores during application were 0 to 2. The wound healing pattern can be seen in Figure 2.

Case 4: Gastrostomy tube–associated dermatitis and PI

An 8-month-old male was admitted to the pediatric intensive care unit for respiratory decompensation. In addition to hypoxic ischemic insult during birth, the patient's co-morbidities included hypertonia, developmental delay, and failure to thrive. His nutrition was being managed with a GT feed. On physical examination, significant breakdown was noted around the GT. Breakdown was diagnosed as device-related PI and dermatitis from excessive movement due to poor GT fit and inadequate securement. The CSG was applied to affected areas and covered by a foam dressing (Mepilex Lite, Mölnlycke). This was regarded as day 1 of treatment. Before CSG application, nurses noticed frequent voluntary scratching attempts by the infant around the GT area. NIPS scores varied around mostly 3 and 4 (mild to moderate pain) to rarely 5. After 2 days of CSG application, his attempts to scratch decreased and caregivers felt he was more comfortable, supported by NIPS scores of 1 to 4.

The wide GT passage allowed continuous leaks of gastric effluent, which created challenges for keeping the wound dry. Hydrofiber ribbon was wrapped around the GT orifice to absorb exudate. Improvements in erythema and edema were clearly noticeable after 2 to 3 days. The depth of PI slowly diminished, and granulation tissue on the wound surface was visible.

Seven days after CSG initiation, dermatitis was resolved, and PI areas appeared to be healing. At this point, CSG application was changed to once every 48 hours. By day 12, complete resolution of PI was observed. The CSG was discontinued after day 14, but use of a foam dressing was continued under and around the GT rims as a precautionary measure. The wound healing pattern can be seen in Figure 3.

Case 5: iatrogenic chemical burn from improper application of silver nitrate application

A 5-month-old female sustained a chemical burn as a result of silver nitrate treatment for hypergranulation tissue surrounding a gastrostomy stoma. The patient was admitted for management of viral gastroenteritis and dehydration in addition to excessive effluent around the gastrostomy site. Silver nitrate was applied to the hypergranulation tissue. As a result of ongoing effluent leakage, residual silver nitrate contaminated surrounding skin, leading to partial-thickness injury with a mix of denuded skin and blisters. The patient appeared to be in moderate pain upon touch; NIPS scores were mostly 4s. A wound consult was called, and treatment with CSG was initiated. This was regarded as day 1 of treatment. The CSG was applied once per shift and was covered with a light foam dressing (Mepilex Lite, Mölnlycke). By day 3 of treatment, erythema and swelling subsided. Denuded skin mixed with thin debris and exudate was easily removed by rinsing with normal saline. NIPS scores decreased to mostly 2 (comfortable). By day 8, a new healing epithelial layer had developed and CSG was discontinued. The patient was discharged on day 10. The wound healing pattern can be seen in Figure 4.

Case 6: chemical burn associated with stomach contents and medications

A 7-month-old male with developmental delay was admitted with fatigue, jaundice, hepatosplenomegaly, and prolonged seizure. Parents reported increased a leak around the GT in the previous 2 weeks. On the day of admission, the patient experienced a prolonged generalized seizure, and the father noticed a copious leak around the GT during the seizure episode. Physical examination revealed a partial-thickness splatter-pattern wound with multiple blisters around the GT. Because the patient was receiving multiple medications, the origin of the injury was thought to be most likely gastric contents that were caustic to the skin. Twice-daily (once per shift) application of CSG covered by a foam dressing (Mepilex Lite, Mölnlycke) was immediate initiated, and this was regarded as day 1 of treatment. Blisters opened by days 2 and 3, and the necrotic skin was gently excised. The CSG was continued twice daily. The patient's GT was changed to a larger size to allow a tighter fit and prevent further leakage. Over the next 4 to 5 days, all injured outer epidermis sloughed off. No infection occurred, and a clean wound bed was maintained. The CSG was continued for 7 days, and by day 10, the areas of burn had healed completely. The wound healing pattern can be seen in Figure 5.

Case 7: surgical wound dehiscence

A 3-day-old female (36-week gestation) who underwent surgery to correct congenital ileal atresia developed surgical wound dehiscence on postoperative day 3. Initial management by the surgical team included packing the wound with moistened hydrofiber twice a day. Slough, lack of granulation, and thickening of wound edges was noticed after 2 days. Wound consultation led to application of CSG covered with hydrofiber to provide exudate absorption. The gel was applied twice a day due to partial dilution by ongoing exudate and mild absorption into the hydrofiber. On day 3, the wound was mechanically debrided by a microfilament pad (Debrisoft, Lohmann & Rauscher, Inc.) to remove slough that was softened by CSG and to remove senescent edge cells. Granulation tissue was visible, and wound edges looked much healthier. A portable, single-use NPWT device was applied in the same visit to expedite closure. A layer of CSG was placed on the wound bed before NPWT application. The wound completely closed after 1 week of NPWT application. The wound healing pattern can be seen in Figure 6.

Case 8: occipital PI

A 5-day-old female (38-week gestation) was evaluated for an occipital PI. The child was born with meconium aspiration and severe pulmonary hypertension leading to respiratory failure, intubation, and placement on high frequency oscillator. Her hemodynamic status was extremely labile during the first 4 days of life, and she required sedation and transient paralysis leading to limited mobility, repositioning, and poor perfusion. Acute kidney injury and significant edema developed. The occipital PI noticed on physical examination on day 5 was likely related to aforementioned factors. Per the National Pressure Injury Advisory Panel, the PI was categorized as unstageable as slough completely covered the wound bed, and the extent of tissue damage within the PI could not be confirmed. Aggressive debridement was not possible as the patient's coagulation profile was partially abnormal.

Treatment with CSG was initiated (regarded as day 1) and reapplied twice a day. The treatment was very effective in softening the slough, eventually allowing its removal with normal saline and gauze. Once debrided, the PI was classified as stage 3. The infant tolerated dressing changes well, and NIPS scores were 1 to 2. By day 8, almost complete closure of the PI wound was achieved. The wound healing pattern can be seen in Figure 7.

Wound treatment patterns in young pediatric patients are similar to those of adults; however, due to difficulty in gauging the comfort level during wound treatment in these pediatric patients, especially in neonates and infants who cannot effectively communicate, the proper selection of wound care products becomes even more important. Demonstration of safety and efficacy of wound care products, such as dressings, for management of wounds in this patient population is essential, as is the creation and implementation of evidence-based clinical guidelines. Due to a paucity of this information, clinical practice decisions are usually taken after consideration of available published literature and expert opinion.

This case series demonstrates that the surfactant-based structure and properties of CSG dressings can play vital roles in enabling favorable wound healing outcomes in young pediatric patients. This dressing forms spherical micelles on the wound bed, such that each micelle contains a hydrophobic core and a hydrophilic surface. The micelle's hydrophilic surface associates with the wound exudate, facilitates easy mobility in the wound environment, and enables its removal with a simple rinse with water, saline, or commonly used wound cleansers at dressing changes. The hydrophobic core of the micelle entraps wound debris and allows for easy removal of trapped debris during rinsing at dressing changes.¹⁸

Pain management and removal of slough are some of the most important concepts in wound care.²⁰ Neonatal manifestations of pain have not been universally recognized by health care professionals; these young patients may not show a vigorous behavioral response to pain as adults and older pediatric patients do, but they experience physiologic pain in a similar manner.²¹ Therefore, pain management during dressing changes, especially in neonates and infants, is extremely vital due to their difficulty in expressing the subjective experience of pain. In this patient population, dressings that require minimum changes are considered more suitable to minimize the inciting factor of pain. In this case series, for most of the patients, the frequency of CSG dressing changes was once to twice daily at the initiation of treatment (by the provider's choice) but eventually became less frequent. Generally, CSG application once daily is well tolerated but can be extended to once every 2 to 3 days if less wound disturbance is desired. This dressing type also offers the advantage of easy application and retention on any part of the body without causing much discomfort and pain^22,23 to these young pediatric patients, as evidenced by their calm temperament during the treatment duration. The behavioral NIPS, which is widely used on full-term and pre-term infants for objective measurement of infant pain or distress (not discussed in detail in this article), revealed that CSG was well tolerated by this young patient population.

Another important concept in wound care for both pediatric or adult patients is removal of necrotic tissue, which is done to prevent infection and promote wound healing. In pediatric patients, sharp surgical debridement is usually not the treatment of choice due to involvement of intense pain. Anesthesia is also avoided due to the age of these patients; therefore, gentle and less-invasive methods, such as autolytic debridement, are preferred. Various types of dressings—such as hydrocolloids, hydrogels, alginates, and transparent films—support and promote maintenance of moisture and provide optimal conditions for wound debridement.^1,24,25,26 In this case series, effective autolytic debridement was demonstrated in all the patients upon application of CSG. A simple rinse with a commonly used wound cleansing solution and a gentle wipe allowed for effective removal of debris. Cases 4 and 8 illustrated examples of PI in a pediatric population. Some PIs may present with slough, and application of CSG can help in slough removal.

Numerous studies have identified the presence of biofilm in wounds and the important role it plays in impairing wound healing process.²⁷ Anti-biofilm properties of wound debridement agents could be of major significance in wound care. There have been numerous in vitro studies showing the anti-biofilm effect of CSG.^28-31 Following the results of these in vitro studies, it is possible that CSG may help to disrupt existing biofilms from wound tissues in a clinical setting and enhance the action of an antimicrobial treatment.³² However, there are no published clinical studies showing the anti-biofilm effect of CSG. In this case series, observations of cases 1 and 2 indicated likely biofilm formation. The CSG was thought to have been useful in diminishing the degree of biofilm formation and enhanced existing layer removal; however, further investigation is warranted. Even though specific laboratory tests were not conducted to show any anti-biofilm effect of CSG on acute wounds in this case series, a general improvement in the wound bed was observed in all the patients by the end of treatment with CSG.

Neonates, especially those born prematurely, are often housed in warm and humidified isolettes. Application of wound healing products can present a challenge as increases in temperature may cause many products to change to liquid consistency and spread beyond wound borders. The thermogelling property of CSG, owing to the presence of a poloxamer as an ingredient, facilitates easy application and removal.^22,32 This property helps in retaining the dressing on the wound bed, ensuring a "stay-put" application. This property of CSG was very useful in all the cases, especially with GT injuries, as the CSG dressing did not migrate or require additional occlusive dressings. Cases 4 through 6 benefited from these properties, as applying and maintaining a dressing on a small concave surface around a GT in a moving baby is difficult. During dressing changes, due to decrease in ambient temperature, the micelles become more attracted to water in the CSG, enabling an atraumatic dressing change experience as the CSG became softer and easier to wash away. The caregivers of case 2 utilized various dressings and shared their positive experience with CSG with regard to ease of application and removal as compared to other dressings.

This study has some limitations. First, it is a retrospective study with potential for recall bias. Second, this is a single-center study, and local wound care practices as well as available products may not be generalizable to all centers. Further prospective and multicenter studies on the subject will enhance the body of knowledge regarding CSG use.

This case series demonstrated pilot evidence for favorable wound healing outcomes in a very young pediatric patient population upon the use of CSG dressing, and it also indicated the product's ease of use in these patients. Additional more extensive, prospective studies on CSG dressing are recommended.

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