My name is Catherine Sybild and I'm going to be going through an approach to pediatric wounds. So pediatric wounds may have different causes and considerations for treatment as compared to adult wounds. A general approach to pediatric wounds are to first determine the cause and contributors, to then think about interventions to treat the underlying cause, as well as wound-directed antibiotics and dressings to encourage healing, and then finally to reassess frequently. So starting off with step one and determining the cause to treat if needed. These are just some general categories of wounds that we more commonly see in pediatrics. So you can have iatrogenic-related wounds from a G-tube insertion, another surgery or trauma. You can have wounds secondary to external forces, so from pressure, moisture, or friction. You can have wounds secondary to inflammatory disease. So acutely, this might include staph scalded skin syndrome, for instance, or chronically from something such as atopic dermatitis or hydrocytis hypertibia that ulcerate. And then finally, you can have infectious causes, and this would include primary infections such as deep fungal, tuberculosis, or bacterial infections, or a secondary infected ulcer from a tumor such as an infantile hemangioma. Another thing that I did not include in writing on this slide is, of course, are genodermatoses that ulcerate, such as epidermolysis bullosa. The next step is to ensure that the infant has enough or adequate protein and nutrition for wound healing. So things that we like to consider are a prealbumin and albumin to look for protein levels, and there is evidence that levels less than 2 grams per deciliter are associated with poor healing. To look for zinc, and while you're waiting for the zinc level to come back, consider ordering an alkphos, which is a zinc-dependent enzyme, to give you an idea of adequate zinc levels. And then finally, an iron and hemoglobin. Now, for patients who have more chronic wounds, such as our epidermolysis bullosa patients, we really do try to be mindful of avoiding unnecessary frequent blood draws, and so using growth charts and body mass indexes as a surrogate can be helpful in this population. Next, it's important to think about analgesic considerations in this population, and you can break it down into physical mechanisms, pharmacological techniques, and then psychological strategies. So for physical considerations, we're really thinking about the dressing application and removal. You want to think about using cleansers that are buffered and don't sting on open areas, but still provide some antiseptic or antimicrobial activity. Think about whether the caregiver holding the child, if they are younger, will be helpful and soothing to the child. Positioning them so that they're not uncomfortable during the dressing change, using some distractions, and then finally using a dressing that is the least thick possible while still giving you that appropriate adhesion to the skin. Next, we'll talk about psychological strategies. So talking to the child as you're removing the dressing, encouraging them to do some structured, long, spaced breathing. Role-playing, using those distractions that we already mentioned, and then allowing the patient to remove the dressing when they're older. Sometimes we'll give them the control and make the experience much more tolerable for them. And then finally, we do have pharmacologic agents that we'll give to minimize the pain with the dressing changes. In the really small infants, we'll consider sucrose both before and during the procedure, and those are doses that are recommended. And then we can also think about acetaminophen, ibuprofen, and morphine for the more extensive dressing changes. Next, we'll talk about the wound-directed treatment, and this includes debridement, antimicrobials, and thinking about optimal physical dressings. For debridement in the low exudate wounds, it's nice to use a topical gel, and there's several different hydrogels that we can use. If it's high exudate, then a dynamic dressing is often preferable, and Aquacel is a nice hydrofiber that forms a gel when it's exposed to liquid, and so can very nicely cope with high exudate wounds. It's very important in children to think about systemic absorption, and topical antimicrobials may indeed have more risks in this population. For each agent, I would ask you to consider the risk of systemic absorption. Does that agent have a narrow therapeutic range? Are there concerning adverse effects if you go above that therapeutic range? And is there a large, broad surface area of open wounds that makes the wound or child more at risk of increased absorption? And just so that you're aware, there are case reports of adverse effects secondary to silver sulfodiazine and neomycin absorption. For low exudate wounds, it's likely safe to use agents such as mupiricin or fucitic acid, and then in high exudate wounds, it's really a case-by-case basis, but often we'll think about antimicrobial impregnated dressings with ones that do not have a narrow therapeutic range. You also may want to think of systemic antimicrobials for deep infections. Always a good idea to do a bacterial swab to characterize the resistance patterns in this selection. All of these three agents listed here are available in liquids, which is nice for children, so cephalexin divided TID, trimethoprim without the sulfamethoxazole component still gives you good staph and strep coverage and is tolerated well, and then clindamycin we often use if we're worried about methicillin-resistant staph aureus, sort of reserving it for those cases because it does taste horrible. Next, we'll talk about selecting the dressings to address the exudate as well as the appearance of the wound. For a contact layer, there's many different options, but most of them are a gauze that is impregnated, and that can either be with Vaseline and or an antiseptic such as iodine or hexidine, and silver really reserve if it's a smaller superficial area to minimize the risk of silver absorption. Hydrofibers, which we mentioned previously, are that really nice option for a high exudate of wound that will form a gel when a liquid is exposed to them. Foams are great superficial dressings for added protection and they can absorb a moderate amount of exudate. And then we'll use a netted overlay like a burn net to help keep the dressing secure. You can also use, such as in the middle there, a tubigrip, which gives them about 10 millimeters of mercury compression per tubigrip layer if you would like some added compression. This is just an example of the way that we adapt dressings to conform to different areas on the body. So we can be quite creative, and these are examples of a toe being dressed, an elbow, cutting the dressing to accommodate fingers in a hand, to accommodate the ear helix, a finger, and then also to form around a tumor with an ulceration in the middle. And then finally, I wanted to end with two specific examples of ulcerations in pediatric populations. The first is an ulcerated infantile hemangioma, and interestingly enough, it's been shown now that wound care alone results in the fastest healing. So this was a review of healing in 436 ulcerated hemangiomas, and wound care alone was associated with the fastest healing. Next was topical timolol that we'll use from an eye drop twice a day on areas. And then finally, a systemic beta blocker, but interestingly here, the shorter healing occurred with lower doses of systemic beta blocker. So up to 1 milligram per kilogram per day, as opposed to the target dose in non-ulcerated hemangiomas, which is more 2 milligram per kilo per day. And this is just an example of an infant that I treated with an ulcerated hemangioma on the ear, and did very well with just wound care alone, as well as seven days of an antibiotic. And then the final case is that of erosive diaper dermatitis. And this was an interesting study that looked at 20 infants with erosive diaper dermatitis and compared Mupiricin to Niacin. And what is interesting from this study is that Mupiricin actually eradicated both candida and bacteria at a higher rate than Niacin. And so one possible routine, which is what I've used in the past, is when there's significant inflammation around the erosive diaper dermatitis, combining that Mupiricin with a medium-strength topical steroid for just a few days. And then to also incorporate the supportive measures of gentle wiping with a preservative-free wipe, and then using a very good barrier cream. And so we like stoma powder in zinc 40% or Vaseline to really make sure that it's very thick and adherent. And then I remind caregivers to only remove the top soiled portion of that mixture with diaper changes, and then replace it with additional mixture on top of that, so that you're minimizing the trauma to the ulcerations. And so then just to review, when we're approaching wounds in pediatric populations, we'll determine the cause and contributors, treat the underlying cause, and use wound-directed antibiotics and dressings to encourage healing, and then reassess frequently. Thank you so much for your time, and I hope this was helpful.

pediatric wounds

pain management

debridement

dressing adaptations

infantile hemangiomas