Pediatric Pressure Ulcer Prevalence — One Hospital’s Experience

    A pressure ulcer is an area of localized tissue destruction directly related to prolonged pressure usually created over a bony prominence by an external surface. The management, financial cost, and suffering associated with loss of skin integrity in hospitalized adult and geriatric populations are well documented.

Prevalence for pressure ulcers in acute care settings for adults ranges between 10% and 18% and the cost for care is estimated in the billions of dollars.^1,2 Nosocomial infection and extended hospitalization are complications of pressure ulcers that contribute immeasurably to emotional costs.³ Consensus guidelines for pressure ulcer prevention and treatment in these populations are widely available.^4,5

    The development of pressure ulcers in children, however, has been less well studied — in part because of their presumed relative rarity compared to adult populations.^6,7 However, a new focus in pressure ulcer research aims to determine whether pressure ulcers are, indeed, relatively uncommon in the pediatric population and takes into account the unique physiologic and psychosocial needs of children. Physiologically, fluid and electrolyte disturbances occur more frequently and develop more rapidly in infants and young children than in older children and adults. The higher proportion of water content and greater surface area of young bodies coupled with the metabolic demands associated with infection and fever increase risk of dehydration. Hypovolemia is a physiologic vasoconstrictor resulting in decreased peripheral perfusion. Skin cells that are not well perfused may be hypoxic and are at risk for breaking down even with minimal trauma. Psychosocially, the very young child depends on caregivers for providing a safe physical environment that includes repositioning and turning. Children who do not have someone to turn and reposition them or children who do not have caregivers educated in the importance of repositioning are placed at a higher risk than those who have a knowledgeable caregiver.⁸

    Knowledge of pediatric pressure ulcer prevalence is essential for planning a pediatric ulcer prevention and treatment program.⁹ To start a pressure ulcer reduction and prevention program in the University of Virginia Children’s Hospital, a major university-affiliated teaching facility, two wound ostomy continence (WOC) nurses completed pressure ulcer prevalence studies of pediatric patients hospitalized in June 2003 and June 2004. Although adult pressure ulcer prevalence studies had been completed yearly for the past 10 years in this institution, this was the first time pediatric data were collected.

Literature Review

    Compared to the number of studies regarding pressure ulcers in adult populations, few published reports relate to the occurrence of pressure ulcers in pediatric populations. A review of PubMed, CINAHL, and MEDLINE databases yielded 10 studies focused exclusively on pediatric patients and pressure ulcers. These studies report prevalence and/or incidence findings from multiple care settings, including inpatient and pediatric/neonatal intensive care units (PICUs and NICUs) as well as outpatient clinics. Other studies focus on the occurrence of pressure ulcers in special populations such as the spinal cord injured.

    In 2003, a multisite pressure ulcer prevalence survey of 1,064 children in nine US children’s hospitals by McLane et al¹⁰ found the prevalence rate to be 4% (n = 43). Study participants ranged in age from less than 10 days to 17 years of age and were hospitalized on general pediatric units and ICUs. The majority of pressure ulcers found were Stage I (61%) and Stage II (13%). Pressure ulcers were most commonly located in the head area (31%), followed by the sacrum (20%) and foot areas (19%).

    In an earlier multisite study of pressure ulcer prevalence conducted by a questionnaire survey mailed to 224 US pediatric healthcare facilities (25% return rate), Baldwin¹¹ reported a pressure ulcer prevalence of 0.47% and an incidence of 0.29%. The study population included children less than 1 year to 21 years of age. The most frequent site of ulcer formation reported was the sacrum/coccyx, followed by heels and occiput.
Curley et al¹² determined a pressure ulcer incidence of 27% (n = 86) in a multisite prospective cohort study of 322 patients ages 21 days to 8 years hospitalized in three PICUs. Patients were assessed throughout their ICU stay three times a week for the first 2 weeks and then weekly. Stage I accounted for 139 pressure ulcers (70%); Stage II, 54 (27%); and Stage III, six (3%).

    Two other studies reported findings from ICUs. In a prospective, matched case-control study of 271 patients, Zollo et al¹³ measured the occurrence of skin breakdown in one PICU for 18 weeks. The reported incidence was 7% for skin breakdown that corresponded to Stage II using the NPUAP description of pressure ulcers. In a study validating the Neonatal Skin Risk Assessment Scale (NSRAS), Huffines and Logsdon¹⁴ assessed skin breakdown in a NICU over 3 months. Six of the 32 infants studied developed skin breakdown that included pressure ulcers for an incidence of 19%.

    Several pediatric studies of prevalence and incidence were reported from the United Kingdom. In a study of 183 children conducted at the Royal Liverpool Children’s Trust,⁶ 12 children developed pressure ulcers — a prevalence of 6.5%. The incidence in 82 children studied was 7.2%. Waterlow’s⁷ multisite study of 302 children ages neonate to 16 years included children hospitalized in NICUs and PICUs and reported an incidence of 6%, where 17 infants and children developed 33 ulcers during their hospital stays.

    Neidig et al,¹⁵ Okamoto et al,¹⁶ and Samaniego¹⁷ reported findings from special populations. In a retrospective chart review of 59 infants and children hospitalized in a PICU following open-heart surgery,¹⁵ occipital pressure ulcer incidence was 17%. This incidence decreased significantly to 4.8% after pressure reduction measures such as repositioning the head were implemented. Okamoto¹⁶ reported data collected over 20 years during outpatient clinic visits at Children’s Orthopedic Hospital, University of Washington on skin breakdown in 524 children with myelomeningocele. Pressure ulcers accounted for 42% of the positive observations of skin breakdown assessed in 227 children. A retrospective chart review¹⁷ of pediatric patients seen in a wound clinic in 1999 revealed a pressure ulcer incidence of 14.6% for patients with myelodysplasia.

    These pediatric studies of pressure ulcer prevalence and incidence confirm that children develop pressure ulcers in various settings, providing a foundation for further inquiry. Two findings reported in the literature have vital implications for the care of pediatric patients: 1) pressure ulcers occur more frequently in intensive care settings and 2) the occiput or back of the head is a vulnerable site for pressure ulcer development in infants.

Methods

    This study took place in a 95-bed children’s hospital located within a larger, 635-bed tertiary care, university-affiliated teaching hospital. This hospital serves as a referral center for the western, largely rural, portion of Virginia; national and international referrals also are received depending on the type of neonatal and pediatric medical or surgical subspecialty care needed. All five pediatric inpatient units (PICU, NICU, two general acute care units, and a rehabilitation unit) were included in the study. The first prevalence study was conducted in June 2003 and another a year later in June 2004. Each study was completed in less than 8 hours.

    Patient population. Each hospitalized child present on the unit at the time of the study was eligible to participate. Patients studied ranged in age from premature infants (some as young as 24 weeks’ gestation) to 21 years. Because skin inspection is part of the bedside RN’s routine assessment, verbal consent was obtained from the parents.¹⁸ Verbal consent was obtained directly from patients 18 years of age and older. The most common admitting diagnoses for all patients were prematurity, congenital deformities, and spinal cord injury.

    Procedure. On the day of the study, two WOC nurses together performed a complete assessment of the patient’s skin with the child in prone and supine positions. Pressure ulcers were staged according to the staging system of the National Pressure Ulcer Advisory Panel. Inter-rater reliability of the data collection tool was established between the two WOC nurses. Content validity was established by another WOC nurse.

    The formula used to calculate prevalence² was:
Prevalence=
Children with a pressure ulcer
_______________________________x 100 
Total # assessed children on the units

Results

    Data on pressure ulcers were tabulated and analyzed using descriptive statistics. In June 2003, the prevalence rate was two out of 77 patients (3%). A year later the prevalence rate was three out of 79 patients (4%) (see Table 1). The results for both years indicated three pressure ulcers were Stage I and three ulcers were unstageable. Pressure ulcer locations included: nares (n = 1), sacrum (n = 1), ankle (n = 1), and heel (n = 3). Pressure ulcers were identified in the Neonatal and Pediatric Intensive Care Units and the Rehabilitation Unit. All pressure ulcers were hospital-acquired; however, one heel ulcer was present at the time of the patient’s transfer from an outside hospital.

Discussion

    The data gathered confirm that children at this institution develop pressure ulcers. Prevalence from the two studies is comparable to the multisite study prevalence rate of 4% reported by McLane.¹⁰ Pressure ulcer location is consistent with previously reported studies of pediatric pressure ulcer occurrence with two exceptions. First, no occipital pressure ulcers were found. The occipital area is a frequently reported site of pressure ulcer development in supine infants and toddlers due to the proportionally larger and heavier size of the head in relation to the body.^15,19 Occipital pressure ulcers are a concern; their occurrence has been linked to the development of scarring alopecia in infants with compromised oxygenation and perfusion or as a complication of extracorporeal membrane oxygenation (ECMO) use.²⁰ Secondly, no pressure ulcers were observed on the ear and chin, two other sites on the head where pressure ulcers develop.^10,12 Interestingly, however, a Stage I pressure ulcer was found on the nares of an infant cared for in the NICU. This pressure ulcer was attributed to the use of a continuous positive airway pressure (CPAP) device.

    Older children are more likely to develop pressure ulcers in locations observed in adults, such as the elbow, sacrum, heel, lateral malleolus, greater trochanter of the femur, and the ischial tuberosities.²¹ The sacrum, ankle, and heel accounted for five pressure ulcer sites observed in this study. The three heel ulcers presented with dry eschar and, as a result, were unstageable. Two patients with heel ulcers were undergoing rehabilitation care and were ambulatory at the time of the study in 2003; another patient with an unstageable heel ulcer was sedated and ventilated in the PICU in 2004. This patient also had a Stage I pressure ulcer on the lateral aspect of the right ankle. Another patient in the PICU had a Stage I sacral pressure ulcer.

    The data also confirm findings in the literature about the risk for pressure ulcer development in pediatric populations. Reported risk factors include critical illness, mechanical ventilation, hypotension, sedation, and immobility,^3,21 while edema, weight loss, and increased length of stay are risk factors pediatric patients have in common with adults.²¹ A level of risk in the patients identified with pressure ulcers in these two studies can be inferred; on the study day, each patient had experienced or was experiencing some combination of risk factors cited in the literature. The presence of these pressure ulcers also calls for a closer look at interventions to prevent these wounds — specifically, measures such as positioning and the selection of appropriate support surfaces designed to reduce tissue load and redistribute pressure away from bony prominences.

    Positioning/support surfaces. Current pediatric practices are modeled on those recommended for adults.⁵ Recommended positioning techniques include a written turning or repositioning schedule, reducing the potential for shear by adjusting the head of the bed to the lowest elevation possible consistent with the patient’s medical condition, and the use of pillows or foam devices to elevate the heels off the bed. One positioning technique unique to pediatric populations is holding the young, small pediatric patient in the caregiver’s arms.

    A role for support surfaces in reducing tissue load in pediatric patients has been reported. One type of support surface — a temperature-stable gel pad — was used in combination with scheduled head repositioning and cited in the literature with minimizing or reducing the prevalence of occipital pressure ulcers in neonates on ECMO.²⁰ Studies of interface pressures in pediatric patients present a clearer picture of support surface needs in these populations. The use of 2- or 4-inch convoluted foam overlays for support surfaces in pediatric patients has demonstrated benefit in reducing tissue load and alleviating pressure at the occiput and the sacrum.²¹ Solis¹⁹ described the efficacy of a 2-inch foam mattress in relieving pressure for infants under 2 years of age and of a 4-inch foam mattress in children ages 2 to 10 years. Pressure reduction was observed in children ages 10 to 14 years on a 2- to 4-inch foam mattress.^19,22 In a more recent study of children from infancy to 16 years, pressure reduction was reported using a 3.5-inch foam with and without a gel pillow that was as effective as a low-air-loss bed.²³

    Pressure-reducing and pressure-relieving support surfaces were in use at the time of the current prevalence studies. The two ambulatory patients in rehabilitation were cared for on a standard hospital replacement mattress designed to be pressure-reducing. The third patient with heel and ankle ulcers was cared for on a pressure-relieving, air-fluidized bed. A schedule for turning every 2 hours was implicit in the nursing plan of care but no written schedule and documentation of turning was present in a review of the bedside chart. The patient was observed to be supine with both heels resting on the bed at the time of the study. The patient with a sacral ulcer was on a standard ICU bed with a pressure-reducing mattress.

    The prevalence findings provide a baseline from which preventive interventions and treatment options can be initiated in the institution. As a result of the prevalence studies, education of the healthcare team about pressure ulcers and their occurrence at this institution has begun. The studies’ findings have been presented at internally sponsored research days for nurses and physicians. A priority audience for education is the nursing staff in the PICU — a care setting with recognized risk factors for pressure ulcer development. The findings also have implications for managing patients as they progress through the continuum of care so a structured education program for all pediatric caregivers is needed. Education of parents and, when appropriate, the child, could occur concurrently. Interestingly, the recent implementation of a hospital-wide minimal lift initiative has provided a serendipitous opportunity for education about pressure ulcer prevention related to the use of a friction-free sheet to avoid shear injury at the sacrum when moving larger pediatric patients.
Changes in nursing practice at this institution are also necessary. Skin is routinely assessed within 24 hours of admission and at least every 12 hours throughout the hospital stay depending on the patient care setting. However, no risk assessment scale for pressure ulcer development is used. The use of such a scale would provide a rationale for instituting preventive interventions earlier, even within 24 hours of admission if risk is identified.

    A research-based approach supports the adoption of the Braden Q scale to assess the risk for pediatric pressure development.²⁴ The Braden Q was adapted by Quigley and Curley²² from the original Braden scale specifically for use in pediatric populations. Its subscales reflect the developmental needs of pediatric patients. For example, the activity subscale includes the descriptor, “patient is too young to walk.”^3,22,24 The addition of the tissue oxygenation and perfusion subscale also distinguishes the Braden Q from the Braden scale.³ Curley et al³ studied the predictive validity of the Braden Q in a population of acutely ill pediatric patients ages 21 days to 8 years and found the performance of the Braden Q similar to that consistently reported for the Braden Scale in adult patients. They reported the Braden Q cut-off score of 16, with a sensitivity and specificity of 0.88 and 0.58, respectively, identifies most pediatric patients at high risk for pressure ulcers while allowing the implementation of preventive therapies for patients with no pressure ulcers at the time of assessment.
The adoption of pediatric-specific pressure ulcer and skin care algorithms similar to those utilized in the adult population at this institution would complement use of this risk scale to guide the healthcare team’s implementation of preventive measures. Documentation of turning and criteria for support surface selection are examples of pressure ulcer interventions that could be further delineated. Because incontinence of urine and stool is associated with skin breakdown (ie, diaper rash and the development of pressure ulcers in the buttocks area), further clarification of appropriate skin care measures in pediatric populations is warranted. Anecdotal observations of skin care practices on the general inpatient unit provide a range of practices and responses. Some practices are tradition-based — eg, baby powder, lotion, or oils are used for infants. Nurses’ and/or physicians’ preferences for particular products to treat skin breakdown can be expensive over time when used indiscriminately without a clear rationale for product use. Psychosocial issues can affect the implementation of skin care interventions for older school age and adolescent patients — these children may resist parent and/or nursing assistance to help clean the perineal area if concerns about privacy and body image are not considered.

    The need for neonatal-specific assessment of risk for pressure ulcers and the adoption of a neonatal skin care algorithm were two other areas for inquiry identified as a result of the prevalence studies. The Neonatal Skin Risk Assessment Scale^14,24 and neonatal skin care guidelines²⁵ published by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) are references that will be useful in directing a collaborative effort with the NICU healthcare team.

Limitations

    The limitations of the study are the small sample size, which limits generalization of the findings to other institutions. The findings would be strengthened by the inclusion of variables such as length of stay, use and duration of mechanical ventilation, use of vasopressors, and nutritional support.¹²

Conclusion

    The authors’ institution will continue to conduct yearly pediatric pressure ulcer prevalence studies. Data collection will assist in identifying trends in pediatric pressure ulcer development. The data also will aid in further evaluating risk in this patient population. Two goals were identified: the education of healthcare professionals and the use of the Braden Q as part of a systematic plan for the prevention of pediatric pressure ulcers. The studies themselves illustrate that measuring prevalence in children can be easily accomplished with huge dividends in ensuring healthy outcomes after hospitalization.

1. Amlung SR, Miller WL, Bosley LM. The 1999 national pressure ulcer prevalence survey: a benchmarking approach. Adv Skin Wound Care. 2001;14:297–301.

2. Cuddington, J, Berlowitz, DR, Ayello, EA. Pressure ulcers in America: prevalence, incidence, and implications for the future; an executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care. 2001;14:208–215.

3. Curley MAQ, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients. Nurs Res. 2003;52:22–33.

4. Agency for Health Care Policy and Research. Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md: US Department of Health and Human Services; 1992. AHCPR Publication 92-0047.

5. Agency for Health Care Policy and Research. Treatment of Pressure Ulcers. Rockville, Md: US Department of Health and Human Services; 1994. AHCPR Publication 95-0652.

6. Willock J, Hughes J, Tickle S, Rossiter G, Johnson C, Pye H. Pressure sores in children — the acute hospital perspective. J Tissue Viability. 2000;10:59–62.

7. Waterlow J. Pressure sore risk assessment in children. Paediatr Nurs. 1997;9:21–24.

8. Hockenberry MJ, Wilson D, Winkelstein ML, Kline NE. Wong’s Nursing Care of Infants and Children, 7th ed. St. Louis, Mo.: Mosby;2003.

9. Baumgarten M. Designing prevalence and incidence studies. Adv Wound Care. 1998;11:287–293.

10. McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey. J WOCN. 2004;31:168–178.

11. Baldwin KM. Incidence and prevalence of pressure ulcers in children. Adv Skin Wound Care. 2002;15:121–124.

12. Curley MAQ, Quigley SM, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4:284–290.

13. Zollo M, Gostisha M, Berens R, Schmidt J, Weigle C. Altered skin integrity in children admitted to a pediatric intensive care unit. J Nurs Care Qual. 1996;11:62–67.

14. Huffines B, Logsdon MC. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Comp Pediatr Nurs. 1997;20:103–114.

15. Neidig JR, Kleiber C, Oppliger RA. Risk factors associated with pressure ulcers in the pediatric patient following open-heart surgery. Prog Cardiovasc Nurs. 1989;4:99–106.

16. Okamoto GA, Lamers JV, Shurtleff DB. Skin breakdown in patients with myelomeningocele. Arch Phys Med Rehabil. 1983;64:20–23.

17. Samaniego IA. A sore spot in pediatrics: risk factors for pressure ulcers. Pediatr Nurs. 2003;29:278–282.

18. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J WOCN. 2000;27:209–215.

19. Solis I, Krouskop T, Trainer, N, Marburger, R. Supine interface pressure in children. Arch of Phys Med Rehabil. 1988;69:524–526.

20. Gershan LA, Esterly NB. Scarring alopecia in neonates as a consequence of hypoxaemia-hypoperfusion. Arch Dis Childhood. 1992;68:591–593.

21. McCord S, McElvain, V, Sachdeva R, Schwartz P, Jefferson, LS. Risk factors associated with pressure ulcers in the pediatric intensive care unit. J WOCN. 2004;31:179–183.

22. Quigley SM, Curley MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcer. J Soc Pediatr Nurses. 1996;1:7–18.

23. McLane KM, Krouskop TA, McCord, S, Fraley JK. Comparison of interface pressures in the pediatric population among various support surfaces. J WOCN. 2002;29: 242–251.

24. Gray M. Which pressure ulcer risk scales are valid and reliable in a pediatric population? J WOCN. 2004;31:157–160.

25. Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. JOGNN. 1999;28:241–254.