Treating Wounds in the Very Young

Through the years, I have been asked to see and treat neonates, infants, and children with wounds of various etiologies. These have included genetic problems, pressure injuries occurring in the hospital, operative wounds, and, as they aged, the full spectrum of trauma and burns. I have always been honored to do so, but it must be remembered that treating the young can present its own challenges. Many who treat infants and children look at them as just small adults and proceed to treat them the same way. I learned very early on that neonates, infants, and children should not be treated as just small adults, because they have issues related to their development, age, and genetics that may make adult treatments ineffective at best and harmful at worst. The selection of dressings and bandages must be carefully based on the condition undergoing treatment, the needs of the wound, and the developmental stage of the child. How common are wounds in neonates and infants? One study showed that 21% of extremely low birth weight neonates can have skin breakdown during the first week of life.¹ It has been found that neonates, infants, and children are “genetically programmed to recover from devastating accidents and debilitating conditions.”² So long as the well-intentioned treatments do not impede the healing process, neonates, infants, and children have a unique advantage due to genetics.

Early issues to address relate to skin moisture and skin fragility. In the very young, the barrier function of the skin to prevent moisture loss gradually develops between 26- and 32-weeks gestation and may only be reached a few weeks before birth. The neonate’s ability to manage heat loss through sweating is only reached about 4 days after birth and can be slower to develop in the preterm neonate. This means moisture control in the skin and body heat management are critical in these children. The fragility of the skin in this population must be considered. I have seen significant skin tears in these children just from removing adhesive dressings. Silicone dressings and minimally adherent dressings should be the dressings of choice. Because of the fragility and thinness of the skin, pressure injuries are not uncommon.¹ Taping tubes and monitoring devices to the skin presents a major problem if not done appropriately. In addition to pressure injuries, it must be remembered that systemic absorption of nearly anything applied to the skin can occur. Silver is one wound care product that can be rapidly absorbed into the skin at very high levels. The long-term effects of this are still under investigation.³

The basics of wound care should be continued in neonates, infants, and children. Debridement of necrotic tissue is important, but care must be exercised. In the younger population, the thin skin can be over debrided very quickly—be careful not to damage underlying tissues and structures with sharp debridement. Enzymatic debridement in children may work well, but it is not approved for use in neonates and infants.

Prevention of infection is critical in these very young patients. The normal antimicrobial defense of the skin does not develop until about 34 weeks of gestation; generally the skin’s immune system is not mature until after birth, which is why sepsis in the very young is so prevalent and important to address.

Treating neonates, infants, and children presents a unique set of challenges but none that the concerned wound care clinician cannot manage. Even with the challenges, helping and treating these patients can be extremely rewarding.