Issue: Volume 65 - Issue 5 - May 2019 ISSN 2640-5245
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Introduction
Last month, I presented the risk factors, assessment scales, and unique specifications for pediatric pressure injuries (PIs). This month I will address treatment.
Most prevention and treatment guidelines stem from adult studies and practice, despite the anatomical and physiological differences between children and adults. Pediatric PIs occur due to a combination of physiologic state and external environment factors that may include:
For neonates (up to 4 months):
Neonatal skin immaturity (thin, underdeveloped epidermis and dermis/poor epidermal-dermal cohesion/lack of subcutaneous tissue/increased edema);
Increased percutaneous absorption of toxic substances, leading to skin injury;
Humidified isolette/humidified and warmed air delivery leading to microclimate and decreased injury threshold;
Poor perfusion/oxygenation;
Lack of communication (eg, poor provider recognition of pain/distress);
Lack of mobility/poor tolerance of repositioning;
Frequent moisture/edema; and
Need for medical devices; and
For children (up to 18 years old):
Poor perfusion/oxygenation;
Lack of communication (eg, poor provider recognition of pain/distress);
Lack of mobility;
Poor nutrition (congenital disorders, critical illness, neuromuscular disorders, intellectual disability);
Need for medical devices;
Developmental immaturity (noncooperative/remove dressings/fear of providers); and
Medically complex children (wheelchair-bound, cerebral palsy, neuromuscular disorders, central nervous system disorders).
Considerations and Treatment
Location. The most frequent locations of pediatric PI are the occiput and areas associated with medical devices such as the head (electroencephalogram apparatus); nose, ears, cheeks (noninvasive ventilation, orogastric tubes); neck (tracheostomy); lips and mouth (endotracheal tube); and hands and feet (peripheral intravenous [PIV], pulse oximeter). These locations explain why treatment of pediatric PIs may present a challenge, including few approved and safe products and difficulty in securing them, nonamenable sites, and application issues (nasal columellar, tracheostomy stoma, mucous membranes).
Stage 1/deep tissue injury.
Dressings. The goal is to prevent further damage and ensure pressure relief, skin hygiene, and good perfusion. A decrease in PIs and their severity has been noted when hydrocolloids, foam, and multilayer silicone dressings are placed prophylactically (see Figure 1). The use of hydrocolloid dressings (comprised of gelatin or sodium carboxymethylcellulose-based gel) is ill-advised in humid and warm environments because pectin-based adhesive softens and may predispose skin to epidermal stripping and skin tears upon removal. Meta-analysishas shown foam is superior to hydrocolloid use; other studies are equivocal. A silicone-dressing releaser can help with hydrocolloid removal.
Pressure-redistribution surfaces. Most of these surfaces are engineered with an adult body in mind, underscoring problems with their use. Children may sink into low-air-loss beds, specialty turning beds may increase occipital friction and shearing, body proportions change, and/or the most protuberant body part (occiput) of a younger child is not appropriately cushioned with standard mattress use. Recently, fluidized positioners have improved neonatal and pediatric surface support. Gel pillows and foam mattresses have been modified to better fit pediatric bodies. Pressure-redistribution surfaces for chairbound children need to be appropriate for the patient’s size (some studies recommend using a foam instead of a gel interface).
Medical device-related PI.
PIV. A polyurethane foam or hydrocolloid pad should be placed under the PIV hub in contact with skin. Tubing should be secured either to the PIV board or on top of foam.
Tracheostomy. PIs can be drastically reduced by prophylactically padding the neck area under the flanges around the stoma and under the ties using thin polyurethane or silicone-based foam, especially during the first 5 to 7 days after surgery (see Figure 2). Moist or saturated dressing should be carefully changed by the ears/nose/throat specialist to avoid maceration.
Noninvasive (eg, binasal prongs and masks) ventilation. Using versus not using a barrier has been shown superior in reducing PI around the nasal columellar, nasal root, and upper lip area. In my opinion, no superior product for this use is currently on the market. The most commonly used barrier is a hydrocolloid variation, which again is not recommended for neonates in a humidified isolette and at risk for skin tears; it should not be removed/replaced for the frequent skin observation currently recommended by governing bodies, and pressure offloading is limited. Foams are used often, but they do not adhere well and are not available precut (see Figure 3). Silicone gel pad use has been reported as well as polyvinyl chloride foam specifically manufactured to be placed on short binasal prongs. The National Pressure Ulcer Advisory Panel and the Children’s Hospitals Solutions for Patient Safety Network recommend prophylactic use of barrier devices and especially when mild injury has occurred.
Gastrostomy. When a gastrostomy tube is in place, it is extremely important to ensure clean, dry skin. Using a nonalcoholic skin polymer may help with maceration. A thin foam or hydrocolloid dressing may help alleviate friction between various outside components and the skin underneath. It is most imperative to immobilize any tubes and tubing padding.
Few topical products have been described in the literature as potential treatment options for areas of columellar injury or around tracheal stoma. European and Asian colleagues have described use of epidermal growth factor, hyaluronic acid, heparin, and peptide-based ointments, but none are available in the United States at this time. Topical antibiotic ointments, petrolatum, and medical-grade honey have been described in case reports, but none has earned a recommendation. Fear of small nostril occlusion precludes many clinicians from putting any product around a nasal wound; the same fear governs tracheostomy stoma area management due to the possibility of direct connection with airway mucosa. Anecdotally, practitioners describe the use of medical honey, nonsting cyanoacrylate liquid, or monomer silver-infused foam around broken skin.
Stage 2/3/4 and unstageable. These PIs represent an open wound. I recommend approaching these injuries as you would any other wound.
Cleaning. Room-temperature, normal saline or mild hypochlorous acid (Vashe Wound solution; Urgo Medical, Fort Worth, TX) can be used to gently irrigate the wound. Alcohol, iodine, or chlorhexidine should not be used in neonates (owing to the risk of systemic absorption, toxicity, and local skin dermatitis), nor are they usually necessary in older children. If used, these products should be removed immediately with saline.
Debridement. Although it is the gold standard, sharp debridement should be the last choice in the pediatric population. PIs in children do not tend to have voluminous exudate or abundant slough. Autolytic debridement choices usually include using a hydrogel, a surfactant-based product, or a medical- grade honey gel. Personally, I tend to use honey, appreciating its hygroscopic, antimicrobial, and fibroblast growth-promoting properties. Medical-grade honey is available in variety of formulations (gel, paste, hydrocolloid, and alginate dressing or rope); I prefer the gel due to the ease of application and manageable viscosity (see Figure 4). My second choice is a surfactant micelle matrix gel. When slough/eschar are thick or extensive, I prefer enzymatic debridement with collagenase. I have used collagenase with great success and no side effects in very young babies (600 g) and in totally immunocompromised patients undergoing chemotherapy. Collagenase has no effects on healthy tissue; in my personal experience, extended application has promoted granulation (probably by keeping the wound base moist and protected). Mechanical debridement with a microfiber monofilament pad or lolly is an excellent tool, especially for smaller wounds. I do not encourage wet-to-dry gauze dressings for many reasons. Although inexpensive, they are nursing labor-intensive, can be painful to remove, lead to nonselective tissue removal, and may spread bacteria.
Topical infection management. Most pediatric PIs are not infected. Many can be colonized, especially in patients with a prolonged intensive care unit stay. Topical antiseptics are not commonly used. Activated Leptospermum honey is an excellent topical antimicrobial. If packing is desired, I choose silver-infused hydrofiber or nonadhesive dialkyl carbamoyl chloride (DACC)-coated bacteria binding mesh. DACC products work by utilizing the principles of hydrophobicity, bacterial binding, and inactivation; silver attacks the cell wall and is bactericidal. For shallow wounds, dressings (foams, alginates, silicone) coated with silver are excellent choices. Silver use in pediatrics is controversial (it is not recommended in neonates due to its systemic toxicity), and its use in older children should be limited to 10 to 14 days due to its toxicity to keratinocytes and fibroblasts and potential to delay wound healing.
Topical antibiotic ointments such as neomycin and bacitracin should be used with caution; children can develop allergic dermatitis with their use. Whether these are effective topical antimicrobials or simply keep wounds moist is not certain. One topical product (mupirocin ointment) has shown better efficacy at eradicating gram-positive bacteria, including methicillin-resistent and methicillin-sensitive Staphylococcus aureus, and it can be used in difficult-to-treat areas such as the nasal columellar.
Improved proliferation. At times, pediatric providers are faced with chronic nonhealing PIs. Some are due to infection while others are due to increased inflammation or poor proliferative signaling. Patients with these PIs are typically critically ill, with increased reactive oxygen burden and inflammatory mediators, and they may be on medications that suppress collagen/fibroblast production. Various biologic dressings from human and nonhuman sources can be used. In my experience, acellular collagen with or without extracellular matrix (ECM) has worked well with immunocompromised patients. Dressings that contain hyaluronic acid deliver vascular endothelial growth factor and have anti-inflammatory and ECM components. Amniotic membrane-based dressings (dehydrated or cryopreserved amnion only or amnion/chorion or amnion/ umbilical cord combinations) are available (see Figure 5). Allogenic dermal/epidermal substitutes occasionally are used in pediatric population. Depending on the dressing combination, they serve as scaffolds, secrete new ECM, and donate growth factors and cells.
Moisture balance/wound protection. Gauze or film dressings are not recommended for PIs, and hydrocolloid dressings are used for protection and to absorb small amounts of exudate. Many clinicians use hydrocolloids for Stage 2 PIs, but I would not recommend hydrocolloids over atraumatic silicone dressings or foams, which I consider the gold standard.3 Alginate, an absorbent, seaweed-based dressing that comes infused with various antimicrobial products, often is used in older children, but its use is discouraged in neonates due to potential calcium release and risk of toxicity. A new generation of compound dressings is emerging, but their use in pediatrics has not been widespread.
Negative pressure wound therapy (NPWT). NPWT has been used successfully in Stage 3 and Stage 4 PIs after appropriate wound preparation. NPWT mechanisms put microstrain on the cells and macrostrain on the edges, remove exudate, stimulate growth factors/oxygenation via increased lymph flow, stimulate fibroblasts, and provide external protection. I have used classic canister, foam-requiring units as well as canisterless, portable, individualized, disposable units. For a wound with moderate to copious exudate and sizable depth, the classic version may work better; for more shallow wounds or for portability purposes, the disposable version is my choice. The disposable units are normally preset to -80 mm Hg; the classic units offer multiple setting options, including instillation and continuous versus intermittent pressure. Younger children can handle pressures of -60 mm Hg to -90 mm Hg, and older children can be provided pressures of -100 mm Hg to -125 mm Hg, similar to adults. Clinicians must be careful during adhesive film removal to minimize epidermal stripping; I always use silicone-based dressing remover.
The issues of intrinsic factors and nutrition are beyond the scope of this article, but always should be on the mind of an astute practitioner.
Affiliations
Dr. Boyar is Director of Neonatal Wound Services, Cohen Children’s Medical Center of New York, New Hyde Park; and an Assistant Professor of Pediatrics, Zucker School of Medicine, Hofstra/Northwell, Hempstead, NY. This column was not subject to the Wound Management & Prevention peer-review process.
