Comprehensive Evaluation and Practical Treatment of Children with Wounds
- Diane D. Sheehan, ND, APN, FNP-BC
- Advanced Practice Nurse, Family Nurse Practitioner
- Disclosure: Dr. Sheehan has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion. Read Diane D. Sheehan's profile
- Shubra Mukherjee, MD
- Attending Physician, Pediatric Rehabilitation Medicine; Assistant Professor of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine
- Disclosure: Dr. Mukherjee has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion. Read Dr. Mukherjee's profile.
Dr. Mary Nevin, Course Director; Vita Lerman, Editor; Dr. John X. Thomas, Senior Associate Dean for Medical Education; Genevieve Napier, CME Director, Tara Scavelli and Jennifer Banys, CME Project Specialist have nothing to disclose.
Other Disclosure Information
At the conclusion of this activity, participants will be able to:
- Describe the risk factors for open wounds in children
- Perform a comprehensive wound evaluation
- Select an appropriate wound care treatment
Estimated time to complete:
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Parents whose infant or child has an open wound will likely seek care and advice from their own primary care provider (PCP). The PCP has much to consider for comprehensive evaluation, holistic care and successful wound management: recall principles of skin healing, perform a complete history to gain perspective of the possible factors associated with impaired skin integrity, and determine if this wound is compromised by comorbidities. Pediatric patients who present with wounds are oftentimes medically complex, yet basic principles of wound healing, practical health management strategies and standard wound treatments can be implemented for wound closure and healing.
Risk factors for open wounds in children
Impaired skin can be a result of a combination of intrinsic issues and extrinsic factors. Key health related intrinsic factors to consider are age, nutrition and hydration level, skin’s pH level, anemia, tissue perfusion and oxygenation. External elements associated with skin breakdown include exposure to excessive heat, moisture, friction shear and pressure.
Skin properties of newborns and premature infants present a unique set of risks. The outermost layer of the epidermis includes the stratum cornea composed of corneocytes (flattened dead cells) with humectants (natural moisturizing factor, NMF, that holds water in the cells) and maintains a low pH of 5.5 in normal skin. This acid mantle controls microbial colonization. However, in newborns the stratum corneum is thinner with less NMF and less sebum. Premature infants’ skin is even more so, and therefore vulnerable to a dysfunctional epidermal barrier with difficulties in fluid homeostasis, thermoregulation and infection control. Infants have increased susceptibility to percutaneous toxicity due to higher surface area to volume ratio, immature drug metabolism systems and decreased subcutaneous fat stores, so careful consideration of product ingredients is necessary. Products with alcohol and iodine-containing compounds used for topical antisepsis can pose a significant risk, in addition to anesthetic creams. [1,2]
Skin breakdown caused by diaper dermatitis is most common with a reported prevalence rate of 16% in hospitalized children.  However, pressure sores which occur less often at reported variable rates between 4%-13% in hospitalized pediatric patients are harder to treat as injury to the skin is persistent. Illness, fever and incontinence can increase susceptibility. 
Pediatric clinical experts developed the Glamorgan Scale, which determined the following statistically significant pressure ulcer risk factors in hospitalized infants and children: [5,6]
- Inability to move without great difficulty, deterioration in condition, prolonged surgery
- Inability to change position without assistance/inability to control body movement
- Some mobility, but reduced for age
- Equipment/objects/hard surface pressing or rubbing on skin
- Significant anemia (Hgb < 9g/dL)
- Persistent pyrexia (temperature > 37.5C for more than 12 hours)
- Poor peripheral perfusion (cold extremities/capillary refill >2 seconds/cool mottled skin)
- Inadequate nutrition (unable to take/not absorbing oral or enteral feeds and not supplemented with hyperalimentation)
- Low serum albumin level (< 3.5 g/dL)
- Weight less than 10th percentile
- Incontinence (if inappropriate for age)
Extrapolating from critical care literature on hospitalized children, risk factors associated with skin breakdown or redness also included age 2 years or younger, length of stay 4 days or longer, requirement for mechanical ventilation and respiratory diagnosis at admission.  The role of intubation duration in the development of pressure ulcers results from restricting movement of the child’s head and the use of sedation and paralyzing agents that reduce spontaneous body movements, all in efforts to maintain a patent airway. 
In children younger than 36 months of age, the head constitutes a greater portion of total body weight and surface area; therefore when supine, the occipital region becomes the primary point of pressure where sores can develop. [5,7] Other pressure ulcer sites include the sacral area, ears and calcaneal regions. This is unlike adults who are more likely to develop pressure ulcers in the sacral region, heels, trochanters, scapula, ankles and elbows.
Fifty percent of pressure sores identified in neonates and children are related to the use of equipment and devices.  With this in mind, any use of equipment such as helmets, CPAP mask, nasal prongs, tracheostomy plates, tracheostomy tubing, arm boards, blood pressure cuffs, casts, g-tube bumpers, orthotic devices, traction boots, wheelchairs and standers require vigilant skin assessments underneath the medical equipment as prevention is the best defense for pressure ulcers. Once skin breakdown occurs, early identification, pressure relieving strategies, more frequent repositioning, education and training for all caregivers is essential.
Comprehensive history, physical exam and wound evaluation
Pediatric patients with wounds require a comprehensive history: past medical diagnoses, co-morbidities, surgical history, illnesses, infections, hospitalizations, review of systems, diagnostic work-up, diet, allergies, medications, family/social history and use of devices/equipment. Specific wound queries can correlate causative factors, help diagnose wound type and guide best individualized treatment strategies. When, where and how did the wound develop? How long has it been present? What care has been provided thus far? What treatments or remedies attempted? Has the wound remain static, regressed or improved over time? Wound evaluation as part of the comprehensive physical exam includes: location, size and dimensions including dead space, presence of healthy tissue, slough, necrotic tissue, wound edges, surrounding tissue, drainage, and signs of infection. Key considerations are summarized in Table 1.
Table 1. Key Physical Exam Considerations
|General appearance: alertness, cognition, mood, vital signs, height, weight (gain or loss since last visit?) body mass index (BMI)
|Heart, lungs, perfusion, pulses
|Musculoskeletal (scoliosis, pelvic asymmetry, muscle atrophy, contractures, spasticity)
|Extremities: pulses (femoral, popliteal, pedal), presence of edema, capillary refill time
|Skin color (pallor palms, nail beds, face, conjunctivae), skin turgor
|Hair distribution (extremity), nail bed
|Sensation: sensory distribution to light touch, hot/cold
|Body site of the wound (where wound is located)
|Wound type: pressure ulcer is typically over a bony prominence/pressure point due to external device, venous ulcer, diabetic ulcer, burn
|Measure: length x width x depth (cm)
|Tracts or undermining (around the clock) – use cotton swab to probe under the edges of the wound, document if present
|Percentage of granulation tissue (% red/pink colored tissue) vs. percentage of necrotic tissue (% yellow / % black / % brown/ % white, etc.)
|If pressure sore, determine if partial thickness (Stage: I, II), full thickness (Stage: III, IV), unstageable, or deep tissue injury
|Edges: circumscribed/uncircumscribed, well-defined, rolled or hyperkeratotic (thick/whitish)
|Peri-wound: describe surrounding tissue color
|Exudate: is drainage scant, moderate, or copious?
|Odor: yes or no
|Consider taking a picture to supplement descriptive factors above
Pressure ulcer stages and categories
According to the National Pressure Ulcer Advisory Panel (NPUAP) official website, the international NPUAP-EUAP pressure ulcer definition is a localized injury to the skin and or underlying tissue usually over a bony prominence, as a result of pressure, or in combination with shear. Pressure sore etiology starts with the normal force of gravity, external mechanical load (shearing included), or forces applied to the skin, which creates pressure gradients that induce deformation of skin and subdermal tissues to breakdown. Pressure ulcers are considered according to the following categories and stages:
Category/Stage I: Non-blanchable erythema – intact skin with non-blanchable erythema of a localized area usually over a bony prominence
Category/Stage II: Partial thickness – partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough
Category/Stage III: Full thickness skin loss – full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed
Category/Stage IV: Full thickness tissue loss – full thickness tissue loss with exposed bone, tendon or muscle
Unstageable/Unclassified: Full-thickness skin or tissue loss – depth unknown – full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow/tan/gray, green, or brown) and/or eschar (tan/brown or black) in the wound bed
Suspected Deep Tissue Injury – depth unknown – purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue injury from pressure and/or shear
© NPUAP. Used with permission of the National Pressure Ulcer Advisory Panel, 2014.
Refer to http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ for full staging/category descriptions.
Principles of wound healing
Inflammation, proliferation and maturation are the 3 overlapping phases in wound healing. At onset of tissue injury, coagulation, fibrin formation and vasoconstriction reduce active bleeding. In this inflammatory phase, leukocytosis also occurs to break down bacteria and cell debris removing it from the wound bed which can take hours, days, weeks or longer. The second phase is of proliferation where fibroblast and endothelial cells lay down a matrix of granulation tissue. Angiogenesis, collagen deposition, epithelialization and wound contraction occur, therefore decreasing wound proportions over time (typically evolves over weeks or months depending on the wound size). These first 2 phases require a moist wound environment for cells to fight infection and to migrate across the wound bed in order to form granular tissue. The last phase of maturation occurs over months to a few years as the collagen remodels and scar tissue evolves to nearly 80% of original strength. 
Wound identification drives treatment strategies. Pressure ulcers require alleviation of the pressure by frequent repositioning and pressure redistribution, which may need improved support surfaces (mattress, cushion, padded orthoses). Diabetic foot ulcer treatment includes the use of pressure-relieving foot surfaces and controlled blood sugars. Venous stasis wounds or open skin areas associated with lymphedema need the gold standard of compression treatment. Overall wound management goals are listed in Table 2.
Table 2. Goals of Wound Management
|Remove barriers to healing
|Eliminate devitalized tissue (yellow/purplish brown/black)
|Establish a well vascularized wound bed with healthy granulation tissue (red/pink)
|Utilize appropriate dressings to support a stable moisture balanced wound environment
|Eliminate dead space with dressing applications
|Reduce colonization (with antimicrobials) and treat infection if present
|Protect wound base and surrounding tissue (use of skin barriers)
|Prevent, treat and minimize pain
|Employ cost effective wound treatment options that are the least labor intensive for compliance
|Collaborate with a well-informed patient and family for effective health management strategies to improve healing
A clinician’s goal is to maximize the percentage of granulation tissue and decrease devitalized yellow fibrinous material, thick and leathery purplish brown or black eschar through several possible methods of debridement. Autolysis is the use of the body’s own capacity to lyse and dissolve necrotic tissue (can occur with an occlusive or semi-occlusive dressing that concentrates and encapsulates white blood cells and enzymes within the wound bed). Enzymatic product use has not been established in children although some anecdotal use has occurred. Mechanical debridement with moist-to-dry dressings can be used so that the necrotic tissue adheres to the woven 8 or 12 ply gauze and the debris can be removed from the wound bed with each dressing change. This process may be painful, so cautiously used in pediatrics. Maggot therapy is very effective in removing devitalized tissue, but is not used much. Lastly, surgical debridement through the use of a sharp instrument or scalpel to dissect the necrotic tissue from viable tissue is a rapid and effective method. Cross-hatching (surgical technique of making a checkered board slits through the thickest eschar) along with enzymes can also debride effectively. Consideration of the patient’s sensations and potential for pain can guide choice of debridement, and use of an analgesic (even topical) may be necessary. Scant bleeding at the base of the wound is beneficial as it releases platelet-derived growth factors that stimulate healing. 
A well vascularized wound bed that is red or pink requires a moist environment to heal; either with a hydration agent (wound gel) or a dressing to retain moisture (an occlusive-type dressing). Hypergranular tissue, an overabundance above the surface of the edges, can also interfere with wound closure and can be managed with silver nitrate sticks or foam dressings. Hypergranulating tissue may indicate ongoing pressure or friction at the wound site.
Wound cleansing and dressings
The most popular cleansing agent to remove debris and prepare the wound surface is normal saline. Avoidance of harsh substances (hydrogen peroxide, alcohol, dyes, preservatives and soaps with fragrances) is advocated, as they interfere with tissue healing. A majority of wound treatment research has been funded by pharmaceutical companies, performed with adults and then extrapolated to use in children. Performance claims of superior wound care dressings and products were often compared to wet or moist to dry dressings (few are randomized studies with controls) so products are difficult to compare.
The goal of product selection in pediatrics is to create or maintain a moist wound environment, control exudate, inhibit bacterial growth, keep contaminants out of the wound, and limit pain and trauma with wound treatments.  Consideration of insurance coverage and economics often drives the use of least expensive dressing. Recommended frequency of dressing change and labor requirements for wound care are equally important for compliance and successful wound management. The most common dressings recommended in pediatrics include hydrocolloids, hydrogels, transparent films, polyurethane foams and gauze.  Close monitoring and altering the dressing types may be required to complement various wound phases throughout the journey of the healing process. Use non-stick dressing options or overlays for comfort and when possible secure dressings without the use of tape (use tubular stretchy gauze) to minimize trauma. A fairly comprehensive list of standard dressing types/categories, their utility and recommended frequency of dressing changes are listed in Table 3 (without promotion of name brands), while Table 4 lists dressing options based on exudate.
Table 3. Standard Wound Care Dressing Options
|Type of Dressing
||Frequency of Change
||Absorbs exudate (can be layered), 8 or 12 ply if using moist to dry dressings for mechanical debridement
||1-3 times daily
|Occlusive film dressings
||Thin occlusive dressing that offers barrier protection; used near IV sites, in skin tears and Stage I pressure ulcers without drainage. May help protect against friction and shear injury.
||Daily to every 3 days
||Adds moisture with gel or impregnated gauze to a dry or minimally exudative wound, promotes autolytic debridement, maintains moist wound environment, beneficial for painful wounds
||Occlusive dressing that offers barrier protection and produces a moist environment; promotes autolytic debridement
||Every 3-7 days
||Absorbs exudate (can be layered), can help with hyper granular tissue
||Daily to every 3 days
||Highly absorptive fibers, absorbs exudate, creates a gel to provide moist environment.May require an outer dressing.If excessive drainage, change more frequently
||Daily to every 3 days
||Contains medical-grade honey, helpful to minimize wound odor, can control bacteria.
||Daily to every 3 days
||Silver ions added to several dressing types for bacteriostatic effect; silver foam and alginates.
||Every 3-7 days
||Contact layer to promote atraumatic dressing changes
||Dependent on underlying dressing
Table 4. Dressing Options Based on Exudate
- Gauze (layer if needed)
- Hydrogels/impregnated dressings
- Contact layers (thin clear, thin hydrocolloids, thin foam dressings)
- Gauze (layer if needed)
- ABD pads
- Highly absorptive dressings Calcium alginates
All wounds are colonized, so distinguishing between a bacterial bio-burden within the wound versus true wound, tissue infection or cellulitis is important. Bio-burdened wounds can improve with bacteriostatic wound products to decrease bacteria; dressings impregnated with silver, methylene blue and gentian violet, manuka honey, or 5% iodoform have been used in adults (cautious use in children). Wounds suspicious for infection demonstrating copious wound drainage, foul odor, erythema and swelling surrounding the edges should have a wound culture obtained, full lab work-up and typically require gram positive antibiotic coverage for 10-14 days. Deep tissue or bone infection with fever may require intravenous treatment, incision and drainage, or surgical debridement and tissue culture.
Malnutrition or deficiencies of protein and other key nutrients may contribute to wound formation or delay wound healing. A comprehensive nutritional assessment; following trends in protein, albumin and pre-albumin levels; and educating families on increasing protein foods, calories and vitamins (A, C, and zinc advised) can enhance healing. A formal nutritional consultation, written educational handouts and website resources can facilitate learning. Treatment of anemia is also key in facilitating healing of wounds.
Wounds associated with diaper dermatitis: Diaper dermatitis (DD) is a common condition seen in pediatric healthcare. Excessive moisture from perspiration, alkaline urine and feces in an occlusive diapered environment can increase skin permeability allowing irritants and pathogens in through the skin barrier. Candida albicans and staphylococcus are common pathogens which can cause infections requiring treatment. With the protective stratum corneum breached, irritation from moisture and friction can cause skin erosions and open lesions that are painful in the perineal area and buttocks. [10-12] Prevention is the goal with the use of emollients or petrolatum to protect epidermal function. When breakdown occurs treatment includes increased frequency of diaper changes and use of higher absorbency products to reduce wetness on the skin. Prudent skin care following episodes of incontinence with no-rinse skin cleansers (pH similar to skin), mild soap with minimal water, liquid cleansers containing emollients, or sterile water (most common in neonatal units) is advocated. Emollients are useful to draw moisture in the stratum corneum and decrease dry skin, and they have anti-inflammatory and antipruritic properties.  After cleansing, application of a barrier protecting agent, such as a no sting barrier film or liquid polymer, can provide a thin transparent breathable barrier and can be used in an infant if older than 28 days old. Barrier creams (zinc based) should be applied thickly and it is advised to refrain from removing completely during diaper changes. If fungal treatment is required, use the anti-fungal cream then layer with barrier cream for added protection from stool. Triple paste or stoma adhesive powders can be used with denuded skin if former methods have yet to improve skin integrity. The use of petrolatum as the second or third layer prevents the creams from sticking to the diaper. [10,13] Hydration and dietary modifications can enhance healing.
Post-surgical wounds: Surgical closure (whether technique involves sutures, staples or glue) allows a bridge of scar tissue to form between the edges for primary intention healing. At times the traction is not maintained due to mechanical forces or increased/excessive drainage. Post-surgical wound dehiscence may require secondary intention healing with an absorptive dressing and sometimes antibiotics. Communication and coordination of post-surgical follow-up is recommended.
Burns: Post-traumatic burns can be followed in primary care settings, dependent on percentage of surface area affected, burn degree and depth, and patient stability. Silver sulfadiazine creams or ointments applied daily for early burn treatment offer an economical choice for large areas to provide anti-bacterial effect and moist wound environment. Post-burn scars oftentimes require long term emollients to manage the dryness associated with the damaged skin.
Slow-to-heal and non-healing wounds: Non-healing wounds require special consideration. Psychosocial factors may impact compliance with wound care recommendations – poor health choices, smoking, skipping meals, insufficiently using dressings, conserving supplies, or depression. Patients and families may require further multidisciplinary team member involvement (dietician, social worker or psychologist). Referrals may be needed to a wound care specialist (Certified Wound and Ostomy Care Nurse, CWOCN), dermatology, endocrinology, infectious disease, occupational therapy, orthotics, orthopedics, physical therapy, plastic surgery podiatry, prosthetics, rheumatology, and vascular surgery.
Advanced wound care treatments used in wound care clinics
Wound care clinics with specialists can employ innovative technologies and advanced wound therapies that have been efficacious with reduced time to healing compared to the standard treatments in adult patients with diabetic wounds, pressure, venous and arterial ulcers. These advanced treatment options include: biologic skin equivalents or bio-composite dressings (porcine dermal collagen or human newborn fibroblasts); negative pressure wound therapy (NPWT) or wound vacuum-assisted closure (VAC), whereby dressings are performed by trained providers typically 3 times weekly (limited time frames and close observation intervals when used in children); tissue engineered growth factors and platelet derivative growth factors (advanced technologically derived additives); pulsatile lavage; electrical stimulation; and hyperbaric oxygen treatment.  These have been shown to be effective in difficult-to-close wounds, such as those with vascular compromise.
Pediatric patients who develop wounds typically have complex medical conditions with multifactorial causes and relationships to the breakdown of their integumentary system. PCPs can fully evaluate the child, institute practical wound treatments and effectively manage health related issues, leading to successful wound closure in most of these patients. Recognition of non-healing wounds and unique patient situations at times require a larger team of providers with more advanced treatment options and settings.
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