Pediatric Patients

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Pediatric wounds are often associated with the idea that they can heal rapidly and that patients have remarkable resilience. This perpetuating thought has resulted in a lack of focus on wound care knowledge in pediatrics1 even though these patients are among the most vulnerable populations. In reality, pediatric patients generally have skin that is more fragile than adult skin, and many of their systems are immature, which can complicate wound care.

Assessment

Although a full-term baby’s skin is structurally similar to adult skin, babies have little more than half the dermal thickness of adults. This thickness increases with age, but pediatric patients generally have much more vulnerable skin than adults.2 The cause of wounds in pediatric patients is also usually different from that in adults. Pediatric patients are more likely to have acute trauma wounds such as from traffic accidents and burns. Chronic wounds are rare but can be caused by medical device–related pressure or friction and shearing.

As in adults, a thorough physical assessment is crucial in developing an effective treatment plan; this includes assessing the wound dimensions, characteristics of the tissue (necrotic, sloughy, etc.), exudate levels, and signs of infection, as well as conducting a thorough review of the periwound area. Regular reassessment will determine whether healing is achieved or whether changes must be made to the management strategy.

One particularly challenging aspect of pediatric wound evaluation is gauging the pain or anxiety of the patient. Fear, stress, or emotional distress in a pediatric patient can increase pain intensity. Further complicating this are communication challenges that exist with infants and very young patients.2 Pediatric pain assessment scales can help to explain the assessment process in a way that adapts to the child’s level of understanding and helps them to communicate in a way that is still clinically useful.

Risk Factors

In pediatric patients with wounds, many additional considerations and risk factors need to be accounted for in the treatment plan. Additional risk factors for wounds found in the pediatric population include the following3:

  • Reduced ability to thermoregulate
  • Increased body surface-to-weight ratio
  • Increased transepidermal water loss
  • Additional concern for epidermal stripping
  • Immature systems (renal, hepatic, and immune), which can increase the likelihood of infection
  • Limited mobility in younger patients
  • Limited communication skills in younger patients
  • Alternative methods for communicating pain
  • Ability to obtain consent for treatment
  • For infants and neonates, a reduced barrier function that is more prone to chemical absorption, bacterial colonization, and infection. Their epidermal skin is also loosely bound to the dermis, thus making them more susceptible to blisters and epidermal tears and more sensitive to adhesives on wound dressings.2 For infants still in diapers, there is also an increased risk of infection and dermatitis that may be relevant in the treatment of nearby wounds.

Treatments and Interventions

There are several key goals in wound management for pediatric patients, including alleviating their pain, reducing emotional distress, and minimizing scarring. As with adult patients, a wound management strategy should take a holistic approach and be patient centered. It should also be comprehensive and include accounting for the following elements:

Pain Management
Regardless of the type of analgesia used, careful attention must be paid to dosing and administration. Doses should be calculated carefully based on the patient’s weight, the type of drug, the administration method, and the ability or inability of the patient to metabolize the drug.2 Pain and anxiety can be expressed in many different ways, depending on the child’s stage of development, and should never be ignored. Detrimental, and sometimes even long-term, physical and psychological effects can be caused by inadequate treatment of high pain and anxiety levels in children.1

Cleansing and Debridement
Wound cleansing for pediatric patients should adhere to standard infection controls. Because of the fragility of their skin, high-pressure methods should be avoided. In neonates and clinically unstable pediatric patients, cleansing the wound may be risky if they have a high risk of bleeding or if they may experience core temperature fluctuations.1

Debridement may be necessary for some pediatric patients to promote healing. Generally speaking, autolytic, surgical, and biological debridement techniques are the standard methods considered for pediatric patients. This decision should be made after adequately taking into consideration the age of the patient and the characteristics, size, and location of the wound.1

Dressing Selection
Many dressings do not come in sizes small enough for many pediatric patients, and some adhesives are not gentle enough for their sensitive skin. Infants and pediatric patients are more prone to skin stripping caused by dressings, so utilization of silicone dressings, which have gentle adhesive properties, should be considered. For very young patients, it is often preferable to avoid adhesives and to secure dressings with a loose bandage or a tubular bandage, when possible.1
In addition to accounting for skin fragility, dressings should also be selected in a way that prevents infection, minimizes pain, and manages exudate.

References

1. White R, Rodgers A, O’Connor L, Anthony D. Paediatric wound care: neonates and infants. Wounds UK. 2016;12(3):8-11.
2. Best practice statement. In: Principles of Wound Management in Paediatric Patients. London, United Kingdom: Wounds UK; 2014.
3. Patel S, Tomic-Canic M. (2014). Neonatal debridement: tricks or treats. J Wound Technol. 2014;1(23):12-13.

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