Chapter 25: Neonatal and Pediatric Issues in Wound Care

Introduction

To health-care professionals, the mere mention of the word "wound" almost reflexively elicits images of chronic, traumatic, or surgical wounds occurring in profiled subsets of adult and geriatric individuals. As though nonexistent, or of lesser significance, wound care in neonatal and pediatric populations is rarely discussed in textbooks and curricula.

Integumentary vulnerability is not typically associated with youth, but rather the converse.¹ (Fig. 25.1) In fact, expectations of innate integumentary resiliency and rapid, uneventful healing based purely on chronology have, in part, perpetuated a lack of wound care knowledge transfer to pediatrics.¹ Despite major technological and surgical advances having increased survival rates among critically and chronically ill neonates and children, wound care practices delivered to this vulnerable population remain antiquated.^2,3,4 Ethical and litigious issues involved in carrying out research in this vulnerable population further convolute this problem, leaving practitioners without evidence on which to base care.³ Most papers on wound care in neonates and children are either anecdotal or are discussions of wound healing principles and clinical practice guidelines for adults.⁵ Safety and clinical efficacy research-based data for wound care dressings, drugs, and adjunctive treatments in neonates and children are desperately needed.^6,7,8,9

Pediatric Skin and Wound Care Practices

There is a paucity of pediatric wound care research upon which to guide clinical practice, with few interventions having been studied in this population.^5,6,7 By default, wound and skin care regimes are commonly based on individual or institutional preference and routine rather than science.⁸ Illustratively, the Pieper et al study of 13 home care agencies reported that while children represented 3% of all visits and 17% of children had wounds, basic wound care principles were not implemented.⁵ In fact, open surgical wounds and pressure ulcers among this pediatric population were often cleansed with hydrogen peroxide, household soap, or povidone-iodine. Forty-four percent were treated with dry gauze and 19% with gauze moistened with normal saline.⁵ Despite these practices, over 90% of the home care nurses interviewed described the pediatric wound care as appropriate.⁵ Similarly, Munson et al found that among 104 neonatal intensive care units (NICUs), fewer than 25% had wound care protocols.¹⁰ A survey of 13 NICUs in the United Kingdom found wound care practices to be widely varied, with no written policy or guidelines available for staff. In fact, 32% of wounds were either left open to air, to desiccate, or were covered with dry dressings, with the prevailing view that plastic surgery would "cure" the wound at a later time.¹¹ Despite 8 of the units surveyed having access to wound specialists, only 1 unit reported using this specialty.^...