Pressure ulcer (or bed sore) in children

By Cristiano Antonino On Jul 16, 2022

A pressure ulcer is also commonly referred to as a pressure sore or decubitus sore. In children, this term refers to a localised area of tissue destruction due to compression, even for a short period of time, of the soft tissue between a bone or bony prominence and an external surface, most often the bed or pram

The external surface may sometimes belong to the child’s body itself, as is the case, for example, with tissues behind the ear that may be compressed between the rigid cartilage of the ear and the mastoid bone that belongs to the skull.

As in the adult, there are five different grades or stages, of which grade I represents the least severe and grade IV the deepest, with tissue injury reaching the bone.

Grade V indicates non-stable lesions, as they are covered by a hard, dark tissue called eschar.

In addition, the pressure ulcer may worsen, thus becoming deeper if left untreated, and may become infected and thus complicated when invaded by aggressive germs

The incidence is 3-5 children per 1000 hospitalised.

50% of ulcers, overall, are observed in children aged 0-10 years.

25% are observed in children under one year of age.

This means that ulcers can affect any age of life, without sparing infants and premature babies.

Pressure ulcers are more often observed in critical care areas and therefore in intensive care or sub-intensive care wards, as in these cases patients are more delicate and fragile and very often subjected to mechanical ventilation, which results in immobilisation of the young patients.

Children undergoing surgery lasting longer than three hours and those undergoing extracorporeal circulation or ECMO are more prone to develop pressure ulcers.

It is not only age that influences the risk, which also varies according to the ward of admission: critical areas of intensive care units have the highest incidence of pressure lesions; it is estimated that 30% of all children admitted to paediatric or neonatal intensive care units have pressure lesions during their hospitalisation.

Admissions to non-intensive wards such as Neurosurgery, Orthopaedics, Plastic and Maxillofacial Surgery and Cardiac Surgery also present a high risk of developing a pressure ulcer.

The children most at risk are those with reduced brain performance (activity) and/or multi-organ dysfunction, i.e. diseases affecting several organs and systems.

Also at high risk of developing a pressure ulcer are the young or wearers of multiple medical devices (devices)

In all cases, the common denominator is children who move little or nothing due to their disease, disability or who have to undergo long-term anaesthetic and surgical procedures.

The most frequently affected sites are the head, and in particular the bone at the back of the head called the coccypsis (38%), followed by the ear (13%), heel (9%), ankle (7%), big toe (6%), sacro-coccyx (10%) and elbow (4%).

More than 50% of pressure ulcers are therefore localised at the level of the head, which in infants is also the largest part of the entire body.

However, only 18% present as very deep pressure lesions, i.e. grade III-IV.

This is why prevention is necessary from the very beginning.

Babies and infants are practically always affected at the level of the occiput because at these ages there is a physiological conformation of the skull (brachycephaly).

The head is therefore round, with a continuous curve and the impossibility of being able to rotate the skull to the right or left to reduce the pressure on the occipital areas, which are more frequently subject to pressure injury. with the absence of an apex: this therefore exposes the occipital area to constant pressure injury along its entire curvature, unlike in adulthood.

An aggravating factor is some particularly fragile categories of young patients, including the disabled, the immobile, the mentally handicapped, the incontinent, spinal and syndromic children, those with chromosomopathies and rare diseases.

In all these cases, continuous dialogue between parents, nurses and doctors is indispensable for the most accurate prevention.

In addition to age, conformation and anatomical features, the type of decubitus in which the child is placed, biometrics also plays a role

Any alteration in the ability to maintain a natural position of all parts of the body, in both waking and sleeping phases (biometrics) creates the conditions for pressure ulcers to develop in unusual and sometimes hidden locations.

These are lesions in neurolesioned children, undergoing neuro-rehabilitation, including postural rehabilitation, who due to forced positions of different parts of the body can develop ulcers in atypical areas such as the face, the edges of the foot, the hip, the outer sides of the knees.

This is why the different, often forced positions assumed by certain parts of the body that are normally free of ulcers may be affected in these situations.

In children suffering from certain neurological syndromes (Guillain-Barré syndrome, Miller-Fisher syndrome), an additional problem is caused by the loss of sensitivity, especially in the extremities, which causes otherwise avoidable injuries, especially to the heel, hands and forearms.

In all these categories, rehabilitation – postural, joint, psychological, neurological – is an indispensable form of prevention.

Once again, a hospital that offers a team of professionals dedicated to difficult injuries, allied in care with their specific skills and interactive with parents, achieves the best results.

In these delicate patients, the prevention of pressure ulcers is based on reducing the impact of the bony prominences on the overlying skin, which is particularly taut and thin

Furthermore, a great help is based on the prevention and reduction of the possible dislocation of bone segments (such as dislocation of the hip, which causes the head of the femur to protrude from the acetabulum cavity, and predisposes the patient to ulceration typical of the external lateral portion of the buttock or thigh).

It is clear that in these patients an individual prevention plan is more necessary than ever, based on personalised care organised around four key points:

Weight control, with a nutritional plan aimed at avoiding malnutrition but also obesity in predisposed individuals, and involving the families, with the need to educate even non-family caregivers.

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Some specific supplements based on essential amino acids and vitamins A, C, E and also containing various trace elements are also useful;

mobilisation by means of appropriate rotation protocols, but also special seating, including pillows, mattresses and wheelchairs.

The rehabilitator’s manoeuvres are also taught to the child’s carer, in order to maintain home mobilisation;

Devices: special attention should be paid to all medical devices (devices), from tracheostomy cannulas to all catheter outflow sites such as central venous catheters; special attention should also be paid to bandages, nappies, connecting wires and cables, and gastrodigestive stomas. Whenever possible, rotation and/or repositioning is carried out, otherwise all contact between the medical device and the child’s skin must be protected with gradually and progressively absorbed foams made of various layers of synthetic materials;
Counselling: by this term is meant a series of talks between doctors/nurses/psychologists and parents, children if capable of understanding and other members of the social group who play an important role in home care. Attempts are made to discourage the natural do-it-yourself attitude, as this creates the conditions for inadequate or even harmful treatment or preventive manoeuvres.
Skin integrity is fundamental, both for the dignity and respect of children and because it influences treatment. Suffice it to say that physiotherapy rehabilitation is sometimes interrupted precisely because of the presence of a pressure ulcer, preventing hydrotherapy or even the ability to wear a brace.

The ulcers are cleaned with disinfectants and bactericides in liquid form, which must not be alcoholic, acidic or coloured to avoid covering the real colour of the child’s tissues and never give pain.

There are many different types of specific dressing – they are called advanced dressings – depending on the production of exudate, the presence of tissue with dead cells, and any local signs of infection.

All dressings must be glue-free and all fixation media must avoid being adhesive so as not to tear the superficial layers of the skin when removed.

Deeper ulcers and painful ulcers can be treated with negative pressure therapy, which is maintained at the site of the lesion by a transparent adhesive film.

In more severe cases, children undergo surgery, in the operating room and under general anaesthesia, to cover the lesion with islands of skin taken elsewhere from the same child.

In more advanced cases, reconstructive surgery using flaps, sometimes only of skin and soft tissue, in other cases also of muscle tissue, is useful to cover and close the deep ulcer definitively.

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