Pediatric Skin Care

 Pediatric Skin Care: Guidelines for Assessment, Prevention, and Treatment

Colleen T. Butler 
Pediatr Nurs.  2006;32(5):443-450.  ©2006 Jannetti Publications, Inc.
Posted 12/19/2006

Abstract and Introduction
Abstract
The review of literature suggests the pediatric population is at risk for skin breakdown and therefore pressure ulcer development. The literature reveals limited information on pediatric skin care issues in comparison to the adult population. The prevention and treatment of pressure ulcers and maintenance of skin integrity in the pediatric population often is not a high priority especially in the critically ill child. Research has demonstrated that children differ from adults in the anatomical sites of skin breakdown; however, treatment remains the same. It is important to have an understanding of the underlying physiology of ulcer formation, the factors responsible for ulcer development, and the factors that put infants and children at risk for developing pressure ulcers. Accurate assessment, documentation, prevention, and treatment are all key factors.
Introduction
The prevention and treatment of pressure ulcers and maintenance of skin integrity in the pediatric population often is not a high priority, especially when caring for the critically ill child. Pressure ulcers are often considered a problem in the adult population; however, research shows that pressure ulcers do occur in the pediatric population. An abundance of nursing research exists on the incidence, prevalence, and cost of pressure ulcer prevention and management in adults (Quigley & Curley, 1996). The available pediatric skin care literature has been based on the adult research in the attempt to meet the special needs of the pediatric population.
Prevention and management of pressure ulcers is multifaceted. One must understand the underlying physiology of ulcer formation, the factors responsible for ulcer development, and the factors that put infants and children at risk for developing pressure ulcers. Accurate assessment, documentation, prevention, and treatment are all important factors.
The skin is an organ that forms a protective barrier against bacteria, chemicals, and physical action, while maintaining a homeostatic internal environment (Bryant, 2000). The largest organ of the body, the skin receives one third of the body's circulating blood. The skin serves many functions: protection, immunity, thermoregulation, metabolism, communication and identification, and sensation. The skin consists of four layers: the epidermis, dermis, subcutaneous fat, and muscle (see Figure 1). In the outermost layer, the epidermis, dead skin cells are constantly being shed and replaced. The dermis, or second layer, has sweat glands, blood vessels, nerve endings, and capillaries, which are all woven together to provide nourishment and support. Destruction to either the epidermis or the dermis can cause systemic infection (Pallija, Mondozzi, & Webb, 1999).

Figure 1. 
The Four Layers of the Skin
Source: KCI's Pressure Ulcer Assessment Tool, 2002. Used with permission.
    
Pressure Ulcer Development
According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is defined as a localized area of tissue destruction that develops when soft tissue (muscle, fat, fibrous tissue, blood vessels, or other supporting tissue of the body) is compressed between a bony prominence and an external surface, for a prolonged period of time (Quigley & Curley, 1996). An ulcer forms when arterioles and capillaries collapse under this external pressure (Bryant, 2000). With the compression of these vessels, the blood that nourishes the cells is cut off, resulting in a limited oxygen supply and a decrease in the transportation of vital nutrients to the cells. These two factors result in tissue hypoxia, causing cellular death, injury to the surrounding area, and ultimately, a pressure ulcer (Pallija et al., 1999). Factors that have been identified as responsible for ulcer development include intensity and duration of pressure, and the tolerance of the skin and supporting surfaces (including soft tissue) to endure the effects of pressure without incidence. De creased mobility, activity, and sensory perception contribute to the intensity and duration of pressure (Quigley & Curley, 1996). Supracappilary pressures cause occlusion of the capillary bed. This pressure leads to the development of localized tissue ischemia, leading to cellular death and tissue necrosis. Increased pressure, over short periods of time and slight pressure for long periods of time, has been shown to cause equal damage (Neidig, Kleiber, & Oppliger, 1989).
Tissue tolerance includes both intrinsic and extrinsic factors. Intrinsic factors include nutrition, tissue perfusion, and oxygenation. Tissue ischemia and damage occur when cells are deprived of oxygen and nutrients, combined with an accumulation of metabolic waste products for a specific period of time. Inadequate nutrition is one of the major risk factors associated with the development of pressure ulcers. Children must be given adequate nutrients to reduce the risk of developing pressure ulcers and to support healing. To achieve this, nutritional support should be designed to prevent or correct nutritional deficits, maintain or achieve positive nitrogen balance, and restore or maintain serum albumin levels. Nutrients that have received primary attention in the prevention and treatment of pressure ulcers include protein, arginine, vitamin C, vitamin A, and zinc (Novartis Nutrition Corporation, 2006).
Extrinsic factors that support healing and reduce the risk of pressure ulcers include: moisture, friction, and shear. Skin injured by friction, two surfaces rubbing together, has the appearance of an abrasion. Typically this type of superficial injury is seen on heels and elbows, resulting from repositioning. Shearing force, such as movement on a bed sheet, creates occlusion by laterally displacing the tissue. Bones move against the subcutaneous tissue, while the epidermis and dermis remain, essentially, in the same position against the supporting surface. This causes a decrease in blood flow to the skin, eventually leading to breakdown (Neidig et al., 1989). Moisture macerates the surrounding skin, causing superficial erosion of the epidermis. Primary sources of skin moisture include perspiration, urine, feces, and drainage from wounds or fistulas.
Risk Factors
Limited information exists regarding the identification of risk factors associated with skin breakdown in the pediatric patient in comparison to those found in the adult literature. However, risk factors that have been identified in the adult population include:
•    immobility
•    neurological impairment
•    impaired perfusion
•    decreased oxygenation
•    poor nutritional status
•    presence of infection
•    moisture
•    acidemia
•    vasopressin therapy
•    surgery
•    hypovolemia
•    weight
It can be assumed that many of these factors would affect the pediatric population, similarly; however, limited research exists at this time.
Review of Literature
A study conducted with postoperative cardiac patients identifies three risk factors for skin breakdown in the critically ill child. These factors include age, length of intubation, and length of stay in the intensive care unit (Neidig et al., 1989). The relationship between age and pressure ulcer formation is due, primarily, to the disproportionately large head, in comparison to body size, in infants and children. In children younger than 36 months, the head constitutes a greater portion of the total body weight and surface area. When children are positioned supine, the occipital region becomes the primary pressure point. Limited hair growth and less subcutaneous tissue contribute to increased susceptibility to the effect of pressure and shearing forces, often leading to pressure-induced alopecia. Vigorous side-to-side movement of the head, as a result of agitation, also increases the shearing force and friction being applied to the head.
Length of intubation plays a significant role in the development of pressure ulcers for several reasons. First, the primary goal is to protect the child's airway. This sometimes means restricting movement and immobilizing the child's head. The use of sedation and paralyzing agents also plays a role in reducing spontaneous body movements. Unless the child's position is changed regularly, the head experiences periods of prolonged pressure. Changing positions can be difficult for the child on extracorporeal membrane oxygenation (ECMO) or oscillatory ventilation. Finally, length of intubation becomes a factor when sedation and ventilator settings are being weaned, contributing to weaning agitation. Again, frequent vigorous side-to-side movement of the head, as a result of agitation, causes friction and shear (Neidig et al., 1989).
A retrospective cohort study of 32 patients, supported with high frequency oscillatory ventilation (HFOV), paired with 32 patient on conventional ventilation in a pediatric intensive care unit (PICU), conducted by Schmidt, Berens, Zollo, Weisner, and Weigle (1998), investigated the relationship of HFOV to skin breakdown on the scalp and ears in mechanically ventilated children. Results indicate a higher incidence of skin breakdown in children ventilated with HFOV than those ventilated with a conventional ventilator (53% versus 12.5%). However, after the data analysis, it was determined that PICU time at risk was the most important risk factor for the development of skin breakdown in this population.
Zollo, Gostisha, Berens, Schmidt, and Weigle (1996) conducted a prospective, matched-case study in a 14- bed PICU in a tertiary care children's hospital. Subjects were assessed, daily, for a change in skin integrity. Data were collected on 76% of all admissions to the PICU. Zollo and colleagues concluded that skin breakdown was affected by many factors; however, the strongest predictors of pressure ulcers were the Pediatric Risk of Mortality Score (PRISM) completed on admission to the PICU, and White race. The Pediatric Risk of Mortality score is used to calculate the risk of mortality for patients admitted to pediatric intensive care units. It consists of 14 routinely measured, physiologic variables, and 23 variable ranges. These variables include systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, PaO2/ FI O2, PaCO2, PT/PTT, total bilirubin, calcium level, potassium level, glucose, HCO3, pupillary reactions, and Glasgow coma score (Pollack, Ruttimann, & Getson, 1988).
Children with spina bifida and spinal cord injuries were tracked over four years at Children's Hospital Medical Center of Akron. Pallija and colleagues (1999) identified 11 risk factors associated with skin breakdown in children with spina bifida and spinal cord injuries: (a) urticaria, (b) obesity, (c) edema, (d) trauma, (e) surgical incision, (f) paralysis, (g) insensate areas, (h) immobility, (I) poor nutrition, (j) incontinence, and (k) impaired cognition.
Samaniego (2003) conducted a retrospective exploratory study at an outpatient wound clinic. The principal diagnoses, identified in the sample, were myelodysplasia (60%), cerebral palsy (16%), and clubfeet (6%); also included were scoliosis, constricted band syndrome, and femoral deficiency. Four primary risk factors were identified: paralysis, insensate areas, high activity, and immobility.
Research has demonstrated that children differ from adults in the anatomical sites of skin breakdown. Six prominent pressure points have been identified in the adult population: the sacrum/ coccyx, heels, elbows, lateral malleolus, the greater trochanter of the femur, and the ischial tuberosities (Meehan, 1994). In infants and children the areas that are affected are the occipital region (primary in infants), sacral region (primary in children), ear lobes, and calcaneous region (the heel of the foot) (Neidig et al., 1989). Baldwin (2002) conducted a national survey of children's health care institutions to determine the incidence and prevalence of pressure ulcers in children. In her study, the sacrum/coccyx was the most frequent site for pressure ulcers, heels the second and the occiput region.
Intervention and Prevention
Early intervention can be an effective preventative measure if patients at increased risk for pressure ulcer development are identified. The principal components for early intervention are (a) identification of at risk individuals, (b) maintenance and improvement of tissue tolerance to injury, (c) protection against the adverse effects of pressure, friction, and shear, and (d) reduction of the incidence of pressure ulcers through an educational program.
Prevention is a multifaceted process. Again, much of the research has been conducted on the adult population, but it can easily be applied to pediatrics. Pressure ulcer prevention begins with accurate assessment to identify an at-risk patient. Various tools exist for assessing adults, and recently the Braden scale, frequently used in adults, has been adapted into the Braden Q scale for pediatrics. Sandra Quigley and Martha Curley developed this scale in 1996. Changes from the original Braden scale reflect the unique developmental needs of the pediatric patient, the prevalence of gastric/transpyloric tube feedings, and the availability of blood studies and noninvasive technology in the acute-care pediatric setting (Curley, Razmus, Roberts, & Wypij, 2003).
The Braden Q scale consists of seven subscales: mobility, activity, sensory perception, moisture, friction/shear, nutrition, and tissue perfusion/oxygenation. The first six originate directly from the Braden scale. Each subscale is rated one through four, with the lowest number representing the highest risk. Total scores range from 7-28 with seven putting a child at the highest risk for breakdown and 28 with no risk (see Table 1 ). In a multi-site prospective cohort descriptive study, Curley and colleagues (2003) studied 322 PICU patients on bedrest for at least 24 hours, without preexisting pressure ulcers or congenital heart defects. They found that acutely ill pediatric patients with a Braden Q score of 16 are considered at risk for Stage II pressure ulcers. The lower relative Braden Q scores that identify patients at risk for Stage II pressures may reflect a unique characteristic of pediatric skin. Younger skin, which has sufficient collagen and elastin, may be more resilient to normal and shearing pressures (Curley et al., 2003).
Early assessment of the risk factors associated with the development of pressure ulcers is essential in their prevention. When an assessment identifies this risk as high, interventions should be implemented to reduce the risk. Preventing mechanical injury to the skin from friction and shearing forces during repositioning and transfer activity is important. The key is to have a sufficient number of personnel available to move a patient. In pediatrics, most patients under 8 years of age can be lifted easily enough to prevent friction and shear. Assistive devices such as lifts, trapezes, transfer boards, or mechanical lifts may be useful adjunctive devices to minimize tissue injury. Remembering to lower the head of the bed, as much as tolerated before repositioning, also will help minimize friction and shear. Mechanical injury from friction can be reduced with application of a barrier dressing, such as transparent films or hydrocolloids, over at risk areas.
Interventions to reduce pressure over bony prominences are of primary importance. A turning schedule must be instituted for patients on strict bedrest. In a study of postoperative cardiac patients, a significant decrease in the incidence of occipital pressure ulcers was observed (16.9% to 4.8%) by instituting a prevention protocol of repositioning the head at least every two hours (Neidig et al., 1989). In addition to turning, heels should be suspended off the bed using pillows or heel lift devices, and the head of the bed should not be elevated for more than two hours to avoid shearing injury to the sacral area. A rolled up blanket is always useful under the patient's upper thighs, or the bottom of the bed can be elevated to reduce the chances of a patient sliding down in the bed. Of course, repositioning is not always an option before hemodynamic and respiratory stability is achieved. Other factors influencing the ability to reposition a patient include line placement, edema of the head and neck, or a positional air leak around the endotracheal tube.
Even with correct positioning methods, a therapeutic surface may need to be used (Bryant, 2000). Although a principal goal in nursing care is to reduce external forces of pressure, shear, friction, and moisture, to prevent or treat tissue injury, frequent turning may be contraindicated in unstable, critically ill children. Examples of such patients include a patient who is hemodynamically unstable, a patient with acute respiratory distress syndrome (ARDS) whose oxygen saturations may decrease with position change, or a patient on ECMO or high frequency oscillatory ventilation.
Another important factor that can reduce the risk of the development of pressure ulcers is the type of surface supporting the patient. The therapeutic benefit of a product and its ability to maintain skin integrity determines which type of surface will offer the best outcome. Airflow through the surface of a mattress will reduce moisture. The material used on the surface of a mattress or overlay will determine the product's ability to reduce friction and shearing. A therapeutic surface should reduce or relieve pressure, promote blood flow to the tissues, and enable proper positioning. The ability of a product to reduce or relieve pressure is determined by its interface and capillary-closing pressure measurements (Bryant, 2000). Capillary-closing pressure is the amount of pressure required to impede the flow of oxygen and blood to the tissues. In a study by Landis, where the microinjection method was used to determine blood pressure in capillaries, 32 mmHg was found to be the average pressure in the arteriolar limb (Quigley & Curley, 1996). Interface pressure is the amount of pressure the resting surface places on the skin over a bony prominence. A pressure reduction mattress reduces pressure, although only to the standard of 32 mmHg, and should be used in patients with more than one turning surface, keeping in mind that the mattress will not provide consistent relief (Quigley & Curley, 1996). These mattresses/overlays lower pressure, compared to a standard hospital mattress; examples include: an eggcrate overlay, air-filled bed, or action bed overlay (also beneficial in reducing shear). A gel pillow is also beneficial under the occiput as a means to relieve pressure.
A pressure-relieving surface is one where pressures are consistently lower than 25mmHg. These surfaces are ideal for children with one turning surface and in need of consistent relief; an example of this is the use of a low air-loss bed, such as the PediaDyne and TriaDyne II beds (Kinetic Concepts, Inc., San Antonio, Texas). A low air-loss bed consists of a bed frame with a series of connected air-filled pillows. The amount of pressure in each pillow is controlled, and can be calibrated to provide maximum pressure reduction for an individual child (Bryant, 2000). The PediaDyne and TriaDyne II beds also offer percussion therapy and rotation. It is also important to note that when a child is on a specialty surface, turning every two hours, as tolerated, is still required for the best outcome.
Assessment and Documentation
Even in the best of circumstances, and with preventative measures in place, skin breakdown can still occur. Accurate assessment and documentation is an essential part of determining the course of treatment. According to Quigley and Curley (1996), "Assessment includes (a) anatomic location, (b) accurate staging, as defined by the NPUAP (1989), (c) size in centimeters (length up and down head to toe, width across and depth), (d) type of tissue at the wound base (including color red, yellow or black), (e) presence of exudate or odor, (f) presence and location of undermining or tunneling, (g) character of the wound margins, (h) condition of the periwound skin, and (I) dressing type" (pg.15).
Undermining is defined as tissue destruction beneath intact skin along wound margins. Tunneling can extend in any direction from the wound surface, resulting in "dead space," creating the potential for abscess formation if the area is not cleansed and packed correctly (Bryant, 2000). Quigley and Curley (1996) found that an optimal wound environment, according to Braden and Bryant, is free of nonviable tissue, clinical infection, dead space, excessive exudate, has a moist wound surface, is protected from bacterial contamination and reinjury, and provides pain relief.
Pressure ulcers are staged according to the NPUAP (1992). A stage I pressure ulcer is defined as an area of nonblanchable erythema of intact skin that does not resolve after 30 minutes of pressure relief and the epidermis is intact. In individuals with dark skin, discoloration of the skin, warmth, edema, and induration may also be indicators. Partial thickness skin loss involving the epidermis, dermis, or both is considered a stage II pressure ulcer. The ulcer is superficial and presents as an abrasion, blister, or shallow crater. A stage III ulcer is full thickness skin loss, involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. The ulcer presents as a deep crater, with or without undermining of adjacent tissue. Stage IV pressure ulcers are those with full thickness skin loss and involve extensive destruction, tissue necrosis, or damage to muscle, bone, or the supporting structure. Undermining or tunneling may also be present in a stage IV ulcer (see Figures 2-5).

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