ORIGINAL INVESTIGATION

Pressure Ulcer Treatment in Pediatric Patients Anna-Barbara Schlu¨er, MScN; Jos M. G. A. Schols, MD, PhD; and Ruud J. G. Halfens, PhD

ABSTRACT OBJECTIVE: To assess pressure ulcer (PrU) treatment in Swiss hospitalized pediatric patients and to determine whether there are differences in PrU treatment, according to demographic characteristics of the patients. DESIGN: A descriptive multicenter point prevalence study was conducted in June 2009 in all German-speaking pediatric hospitals in Switzerland. SETTING: All hospitalized patients from birth up to 17 years or younger in 14 Swiss pediatric hospitals, including all pediatric departments, were assessed. PATIENTS: A total of 412 patients participated in this study. MAIN OUTCOME MEASURES: The instrument and method of the Dutch National Prevalence Measurement of Care Problems were used. MAIN RESULTS: Thirty-five percent of the patients had a PrU. Almost all of these PrUs (94.1%) were of category 1. The most severe PrUs occurred in patients older than 8 years. Age of the patient and department were the only characteristics that significantly influenced the occurrence of PrU categories 2 to 4. Pressure ulcer categories 2 to 4 were mostly covered with hydrocolloid or polyurethane foam dressings. No pediatric-specific guideline regarding PrU treatment is used in the involved hospitals. CONCLUSION: Most patients had category 1 PrUs, so appropriate prevention to decrease any further trauma in these patients was necessary. Severe PrUs (categories 2Y4) are mostly limited to older pediatric (aged 98 years) patients with chronic conditions or after surgery intervention. A PrU treatment guideline adapted for pediatric needs is recommended. KEYWORDS: pressure ulcer, pediatric nursing, wound care in pediatrics, negative-pressure wound therapy ADV SKIN WOUND CARE 2013;26:504Y10

INTRODUCTION A pressure ulcer (PrU) is a localized injury to the skin and/or underlying tissue as a result of pressure or pressure in combina-

tion with shear forces.1 Although PrUs have gained significant attention in adults, far less is known about PrUs in children and neonates.2 Recent investigations indicate that PrUs are also common in hospitalized infants and children: reported PrU prevalence rates in children, including all PrU categories, range from approximately 3% to 35% in hospitals.3,4 In some pediatric care settings, such as neonate departments and pediatric intensive care units (PICUs), the PrU prevalence rate may rise to as high as 50%.4 Although it is well known that the costs for PrU treatment in adult patients are extensive,5Y8 only vague suggestions have mentioned that the costs for the pediatric population are comparable to those for adult patients.9Y12 There are several guidelines for wound treatment in adult patients regarding the treatment of PrUs, as well as wounds in general.13Y19 To the authors’ knowledge, no specific guideline for wound treatment in pediatric PrU wounds is available today. Epidemiological studies and empirical evidence state that the most common wound types in pediatric patients include epidermal stripping, extravasation injuries, surgical wounds, incontinenceassociated dermatitis, chemical and thermal injuries, wounds secondary to congenital abnormalities, and PrUs.2,20 Caring for young versus adult patients presents a number of relevant differences,2,10,12,21,22 which challenge the management of acute and chronic wounds of various etiologies in the pediatric population.21 Because of their small body sites, especially in newborns, neonates, and infants, pediatric patients present a challenge for finding an appropriate wound treatment.2 The skin of newborns, infants, and children is morphologically and functionally different from that of adults.23,24 Appropriate pain management, age-appropriate communication strategies according to wound treatment, and early mobility and activity, especially in infants and toddlers, all add a greater aspect of complexity in wound care.12,25 Small dressings that are easy to apply even to the small fingers and toes of very small neonates with adequate adhesion, but which do not stick to the skin, are necessary to meet specific pediatric needs.21 Only a few research publications about the treatment of pediatric PrUs could be found. In the study of Cisler-Cahill,26 a total of 48 wounds of all types were treated with amorphous hydrogel

Anna-Barbara Schlu¨er, MScN, is a Nursing Scientist in the Department of Nursing Development and Science, and the Children’s Research Center, at the University Children’s Hospital Zurich, Zurich, Switzerland. Jos M. G. A. Schols, MD, PhD, is a Professor in the Departments of Family Medicine and Health Services Research; and Ruud J. G. Halfens, PhD, is an Associate Professor of Nursing Science in the Department of Health Services Research, both at CAPHRI-Maastricht University, Maastricht, the Netherlands. Acknowledgments: The authors thank all the nursing staff and chief nursing officers of all the hospitals involved for their active and interested participation in the study assessment. They also thank all the children and their families for their contribution. In addition, the authors thank Dr Heather Murray for her support in revising the article’s English. The authors have disclosed they have no financial relationships related to this article. Submitted March 4, 2013; accepted April 18, 2013. ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11

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and healed without surgical intervention. In addition, PrU-related wounds were included, but no information on the number, severity, or localization of the PrUs or on the explicit treatment and duration of a wound was given. In 3 case reports on forehead pressure necrosis wounds in neonates following continuous positive airway pressure, these PrUs were treated with hydrocolloids for an unknown time period. The PrUs were not categorized, but described as pressure necrosis. In all 3 cases, a slight but visible scarring remained after an 18-month follow-up period.27 In a study of 79 children with cerebral palsy undergoing osteotomies by Stasikelis et al,28 5 children developed a PrU (not categorized) after cast removal. The wound treatment was conducted with undefined local wound treatment without interfering with the planned rehabilitation program. All 5 PrUs healed within 2 to 8 weeks.28 In a study on the surgical treatment of PrUs, the successful technique of specific muscle flap operations in pediatric patients with ischial PrU categories 3 and 4 is described.29 In another study, the long-term outcome of surgical reconstruction of pediatric PrUs is described.10 In this study, a total of 19 paraplegic patients between ages 9 and 16 years with 20 PrUs localized as sacral (n = 7), ischial (n = 9), trochanteric (n = 3), and iliac crest (n = 1) were treated surgically with myocutaneous flaps. The overall PrU recurrence rate after treatment was 1 of 20 (5%). The long-term follow-up over a 5-year time period showed that the treatment was successful and provided long-term skin integrity.10 In 3 studies, the use of negative-pressure wound therapy (NPWT) for PrU-related pediatric wounds was studied.12,21,30 In the study by Bahasterani,20 3 PrUs were treated with NPWT, with a total closure of the wound in 2 PrUs and 80% closure of the wound in 1 case. In the study by Gabriel et al,12 5 patients all showed categories 3 and 4 PrUs (children aged 3Y12 years [n = 2]; adolescents aged 13Y21 years [n = 3]). After a 15-day NPWT treatment in these patients, 2 PrUs were closed completely (40%), and 3 wounds needed further treatment. No further references to age or treatment were made.12 In the clinical review of Bahasterani,20 the recommendation was made that NPWT should be used in PrU categories 3 and 4. However, categories 3 and 4 PrUs were not further described in this study.20 Up to now, there has been a lack of knowledge and research to guide clinical practice in the field of PrU treatment in pediatric patients.11,22,25,26

STUDY PURPOSE Because of this lack of knowledge, the following research questions were formulated for this study:  Which pediatric patients show severe PrUs of categories 2, 3, and 4 compared with patients at risk (patients with category 1 PrU)? WWW.WOUNDCAREJOURNAL.COM

 What is the current PrU treatment in Swiss pediatric hospitals?  Are there any differences in the treatment of severe PrUs

(categories 2Y4) according to demographic characteristics of patients?

METHODS AND PATIENTS In 2009, a multicenter, cross-sectional, point prevalence study was conducted in all 14 pediatric hospitals in the German-speaking part of Switzerland (this is a geographical term for a region of Switzerland) on 1 day in June.4 These 14 hospitals had a total of 70 wards. All pediatric departments at the participating sites were included. Children in all departments, including PICUs, neonatal intensive care units, all surgical units, all pediatric medical units, as well as the departments for pediatric rehabilitation care, were invited to participate if they met the inclusion criteria. Inclusion criteria were an age of 24 hours up to and including 17 years and being hospitalized for at least 1 day in the respective institutions. Exclusion criteria were (a) hospitalization in psychiatric units, (b) children whose legal representatives did not allow participation, and (c) children who refused to participate; this included no informed consent form from children 10 years or older, as well as younger children who verbally refused to participate.4

ETHICAL APPROVAL The ethics board of each hospital and all cantonal ethics committees approved the study. All patients and their families were verbally informed about the study and also received the same information in written form. The information letter and the informed consent form were available in 8 different languages. Children aged 10 or older were asked to give their own written consent, in addition to a written informed consent of the parents/legal representatives; in other cases, the parents or legal representatives were asked to do this.4

MEASUREMENTS The instrument and method of data collection of the Dutch National Prevalence Measurement of Care Problems31 were used to assess the treatment of PrUs. This instrument is widely used in Europe and other regions and has been shown to be reliable and valid.31 Among other information, the instrument collects the following categories of data on a patient level: (1) patient characteristics (demographic and clinical data), (2) assessment of the severity of PrUs, and (3) prevention and treatment interventions. Furthermore, a few questions were asked about the policy of the hospital and ward regarding PrUs, such as if they have a guideline for PrUs.

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tributions and frequencies were calculated and tested with the W2 test (categorical data) and 1-way analysis of variance.

To differentiate risk factors for the development of more severe PrUs (categories 2Y4), patients with a PrU category 1 were defined as patients at risk. This correlates with Bahasterani et al21 and with recommendations from pediatric-specific PrU research findings,32 whereas PrU category 1 seems to be the most important risk factor for pediatric patients to develop severe PrUs. The method of data collection related to PrUs involved a direct and systematic inspection and judgment of the skin of the patient. The European Pressure Ulcer Advisory Panel PrU category system consisting of 4 categories was used.1 Demographic and clinical data, such as date of birth, weight and size, body mass index, and diagnosis, were collected from the patient charts. The wound treatment applied was assessed by direct inspection, as well as by analyzing the patients’ charts and wound documentation.

RESULTS The overall sample size of potential study participants who met the inclusion criteria was 560. The total number of participants was 412 (74%) because 148 (26%) dropped out before the assessment. In 67 cases (12%), either the parents or the child refused to participate. Sixty patients were excluded because of unexpected discharge or because examination or operations lasted longer than the survey (11%). Four patients were not assessed because of an unexpected change in their condition to a critical level. Five patients dropped out because of language barriers with the parents, and for 12 patients, the reasons were unknown.

PROCEDURE

Demographic characteristics

Previously trained rater pairs gathered data from each patient. Each rater pair consisted of a healthcare worker who worked on the ward surveyed and a healthcare worker who did not work on that ward. A total of 35 rater pairs were involved in the study. In all participating hospitals, nurses who worked either as wound consultants in their units or as clinical nurse specialists acted as raters. Preparatory training included methodological aspects, detailed information about data collection, the role and responsibilities of the raters, a detailed introduction to the measurement instruments, and special training in the grading of a PrU.

As presented elsewhere,4 the participation rate in the 14 clinics ranged from 6 to 97 patients (43%Y100%). The length of stay showed an average of 25 days and a median of 7 days. Of the 412 assessed patients, 67% (n = 275) had been hospitalized for fewer than 14 days. Patients with an oncology diagnosis, acute gastroenteritis, pneumonia, or cardiology diagnosis represented the largest group with 33% (n = 135) and were classified as pediatric medical department patients, followed by neonates (n = 109, 27%) and patients in the surgery departments (including plastic and burn surgery, visceral surgery, neurosurgery, and orthopedic and trauma patients) (n = 99, 24%). The patient population in the PICU consisted of 36 children (9%). In addition, 33 patients (8%) were hospitalized for rehabilitation care (Table 1). Eleven of the 14 hospitals (78%) had a guideline for PrU treatment, but none specific for pediatrics, and 19 of the 61 wards

DATA ANALYSIS Predictive Analytics Software (version 18, formerly SPSS) was used to analyze the study data with descriptive methods. Dis-

Table 1.

DEMOGRAPHIC CHARACTERISTICS OF THE STUDY SAMPLE Mean Sex

Median

SD

n (%)

Female Male

Age, y Age, mo Age group G1 y of age, wk Age category, y

181 (44) 231 (56) 4 52 6

1 14 3

5.4 66.7 9

G1 1Y4 4Y8 8Y12 912

203 203 61 44 43 61

(49) (49.3) (14.8) (10.7) (10.4) (14.8)

99 135 33 109 36

(24) (33) (8) (27) (9)

Duration of stay related to divisions, d Surgery Pediatric medical Rehabilitation Neonatology PICU

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9.13 17 110.4 19.9 14.8

506

4 4.5 64 14 7

16.6 44.8 137.9 20.9 16.2

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(31%) did not work according to a PrU treatment guideline. In the last 2 years, 8 of the 14 hospitals (57%) organized extra training on the prevention and treatment of PrUs, but based the prevention and treatment of PrUs only on adult patients.

Prevalence of PrUs Of the 412 patients taking part in this study, a total of 142 showed 1 or more PrUs on the day of inquiry, which involved a PrU prevalence rate of 35%. And, of these 142 patients, 77 (54%) showed 1, 35 (25%) showed 2, 17 (12%) showed 3, 6 (4%) showed 4, 2 (2%) showed 5, 3 (1%) showed 6, 1 showed 9, and 1 patient showed 10 PrUs. This resulted in a total number of 269 PrUs. Almost all of these PrUs (94.1%) were of category 1, which the authors defined as at risk of PrU (Table 2). The age of the patient and the department where the patient was hospitalized were the only factors that significantly influenced the occurrence of categories 2 to 4 PrUs in comparison with patients with category 1 PrUs, whereas gender, body mass index, and whether the hospital had a guideline according to PrU prevention and/or treatment, had extra training, or worked according to a PrU guideline at the ward were not statistically significant. Patients in a pediatric medical department or a surgery department (W2 = 12.005, P = .017) or who were older than 8 years showed more severe PrUs (P = .000, F = 12.269).

TREATMENT Tables 2 and 3 list the wound treatments/wound dressings applied in PrUs according to category. In nearly 80% of all PrUs belonging to category 1, no dressings at all were used (n = 205). The use of ointment with a high level of lipid was common in 7% of category 1 PrUs. Hydrocolloid dressings were used in 6 patients (2.3%), as well as paraffin gauze dressings in 3 patients (1.2%). In more than half of all the PrU cases of category 2, no

dressing was used (n = 7, 64%) (Table 2). Categories 3 and 4 PrUs were treated with different dressings and treatments, including the use of NPWT in 1 case (Table 2). Of all available wound dressings, at the 14 clinics involved in the study, only ointment (7%) and hydrocolloid dressings (3%) were used frequently (Table 2). Other dressings (5%) included a variety of dressings that were used for PrU treatment. In category 1 PrUs, these included the use of a special biosynthetic skin substitute, the use of an antifungal solution, and the use of creams brought by the family of the patient. The 1 category 3 PrU (treatments score ‘‘other’’) was disinfected and not covered, and the PrU rated as category 4 was treated with NPWT (Table 2).

DISCUSSION This study’s goal was to survey the treatment for PrUs in pediatric wards in German-speaking Switzerland. The results revealed a range of different treatments primarily related to differences in severity and location. In discussing the results, a distinction will be made between category 1 and categories 2 to 4 PrUs. It seems practical that most of the category 1 PrUs were not treated with a wound dressing because the skin is still intact in these wounds.1 The nonuse of any dressing in category 1 PrUs makes it possible to recognize any changes in these ulcers quickly and easily. In addition, it is very important to administer appropriate preventive interventions in pediatric patients with a category 1 PrU to avoid any further trauma to the skin.2 Regular risk assessment, daily skin assessment, repositioning, and pressure relief are all components of effective PrU prevention.33 These preventive interventions need to be adapted to pediatric patients with regard to the varying needs in different age groups, such as neonates and infants, as well as in settings such as the PICU.33

Table 2.

WOUND DRESSINGS USED IN THE 142 PATIENTS WITH A TOTAL OF 269 PrU CATEGORIES 1 TO 4 Wound Dressing

Category 1

No dressing Ointment Hydrocolloid Paraffin gauze dressing Polyurethane foam dressings Drying out/air dry Alginate Oil Dressing containing silver Film dressing Others Total, n (%)

205 20 6 3 1 3 1 1 1 1 11 253 (94)

a

Category 2

Category 3

Category 4

7 2 1 2

1 1

1 3 (1)

11 (4)

1a 2 (1)

n (%) 212 20 8 4 4 3 2 1 1 1 13 269

(78.8) (7.3) (3) (1.5) (1.5) (1.2) (0.7) (0.4) (0.4) (0.4) (4.8) (100)

NPWT.

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Table 3.

DIFFERENTIATION OF PATIENTS WITH CATEGORIES 2 TO 4 PrUs ACCORDING TO TREATMENT AND PATIENT CHARACTERISTICS Length of Time Since PrU Wound Localization Occurrence Treatment

Age of Patient

Division/Subdivision/ Medical Treatment/ Medical Diagnosis

Suspected Cause for the PrU Development

Duration of Patient Stay

Category 2 1+ Heel

2Y4 wk

Hydrocolloid

11 y

Surgery/orthopedic, spinal cord

Cast

99 d

2+

Heel

2Y4 wk

Hydrocolloid

11 y

Cast

99 d

3*

Hip

2Y4 wk

No

8y

Postoperative

15 d

4*

Hip

2Y4 wk

No

8y

Postoperative

15 d

5-

Heel

3Y6 mo

No

11 y

Shoes

10 d

6-

Heel

3Y6 mo

No

11 y

Shoes

10 d

7

hand

G2 wk

No

8y

8

Heel

G2 wk

No

15 y

9a

Heel

3Y6 mo

Polyurethane foam

16 y

10a

Heel

3Y6 mo

Polyurethane foam

16 y

11

Ear

G2 wk

No

Surgery/orthopedic, spinal cord Surgery/neuroorthopedic Cerebral palsy Surgery/neuroorthopedic Cerebral palsy Pediatric medical juvenile arthritis Pediatric medical juvenile arthritis Pediatric medical/type 1 diabetes Surgery/orthopedic Cerebral palsy Pediatric medical/ oncology Sarcoma Pediatric medical/ oncology sarcoma Neonate, 28 wk of gestation

Category 3 1 Heel

3Y6 mo

Alginate

Cast

127 d

2

Sacrum

2Y4 wk

Polyurethane foam

Cast

27 d

3b

Femur

91 y

Other, disinfection and no cover

17 y

Surgery/orthopedic Femur osteotomy Surgery/orthopedic Hip reconstruction Cerebral palsy Surgery Cerebral palsy Chronic PrU

1

Heel

G2 wk

Paraffin gauze dressing

9y

2b

Sacrum

91 y

Other, NPWT

17 y

5d

17 y 8y

Splint of peripheral intravenous cannula Positioning postoperative

Further Comments First description of PrU after cast removal First description of PrU after cast removal

First occurrence of the PrU at home

5d 6d

Positioning

1 day

Decreased sensitivity, after tumor excision

Positioning

1 day

Decreased sensitivity, after tumor excision

Continuous positive airway pressure mask fixation

5d

PrU development in another hospital

141 d

PrU occurrence at home for handicapped

1 wk

First 5-d treatment at ICU

141 d

PrU occurrence at home for handicapped

Category 4 Surgery/plastic reconstructive polytrauma Surgery Cerebral palsy Chronic PrU

+/*/-/a/b: marks PrUs of the same patient.

Concerning the use of hydrocolloid and polyurethane foam dressings in 3% of all category 1 PrUs, this may have been done for preventive reasons to protect an affected or vulnerable skin area from further trauma.11,34 Clinicians should be aware that hydrocolloid dressings used for the prevention of PrUs, as well as ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11

for the protection of further trauma of PrU sites, are more commonly used in daily practice along with devices such as splints or tubes in pediatric patients. To the knowledge of the authors, this is often conducted in daily practice; however, no literature was found to evidence that practice.

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The use of ointment (7%), as well as oil (n = 1), in category 1 PrUs might also be judged as a preventive intervention. However, the use of ointment, oil, or antifungal solutions or creams brought by the family for patients with a category 1 PrU is not in line with recommendations in the literature.11,22,30,34,35 Although these products may be related to the patient’s normal skin care, it was not clear if that was the case in this study. Routine use of any ointments, oil, or related products is not recommended for skin care in pediatric patients, especially in neonates and children younger than 5 years.11,35Y39 Infant skin differs from adult skin in structure, function, and composition. It has to be noted that infant skin is not as resilient as adult skin when it comes to skin care routine. Its unique properties should be taken into consideration and appropriate skin care products that focus these needs should be chosen. Further research is needed in this area. The use of paraffin gauze, alginate, and silver dressings for the treatment of category 1 PrUs should be an evidence-based decision. It may be thought that there is no primary treatment indication for these dressings in category 1 PrUs (which still imply intact skin) and that all these dressings need a secondary dressing, thus obscuring the PrU. This means that a category 1 PrU cannot be assessed easily without changing or removing the dressingsVa task to which children may be more sensitive. Finally, because of cost-related factors, this strategy should not be recommended.40,41 The use of any dressing in pediatric patients must rely on a clear goal for the intended treatment and must protect the skin from further harm, such as epidermal stripping.11,30,41 Regarding the treatment of categories 2 to 4 PrUs, the use and type of dressings found in this study seem reasonable. The use of polyurethane foam dressings, as well as hydrocolloid dressings, is in line with recommendations for the pediatric population.11,30,41 The authors can only surmise why 7 of the category 2 PrUs (64%) were not covered with any dressing. If these category 2 PrUs involved blisters with still intact skin, then this strategy can be understood. Any change in the category 2 PrU can be assessed easily, and unnecessary wound dressing changes avoided. Of course, appropriate preventive interventions to avoid further trauma of blisters are of great importance. If the blister breaks, however, an appropriate dressing subsequently needs to be chosen.41 The use of an alginate dressing in a category 3 PrU also seems appropriate. Pediatric wounds classified for the use of an alginate dressing mostly show partial- and full-thickness skin loss.22 The control of bleeding from a wound using alginate has been studied in adult patients but not in children.20 In fact, the use of calcium alginate in neonates is not recommended because of the unknown absorption of calcium in these patients.20 In this study, the patient with alginate treatment of a category 3 PrU was 17 years old. WWW.WOUNDCAREJOURNAL.COM

Negative-pressure wound therapy for PrU treatment is highly recommended in some studies in pediatric patients with, for example, PrU wounds and acute and chronic wounds with partialand full-thickness skin loss and considerable exudation.12,20,25 The advantages of NPWT use in pediatric patients are well described in those studies. In the present study, NPWT was used in only 1 case of a category 4 PrU. As described in the literature,10,12,20,28,42 a comparatively high proportion of surgical patients, especially patients after orthopedic treatment or patients with cerebral palsy and spinal cord lesions, showed categories 3 and 4 PrUs and were older than age 8 years in this study. This suggests that older pediatric patients with chronic conditions may be affected by more severe PrUs. In more than half of all institutions surveyed, a PrU treatment guideline was available, but none were adapted to the needs of pediatric patients.

LIMITATIONS OF THIS STUDY AND IMPLICATIONS FOR FURTHER RESEARCH Prevalence studies are always subject to daily variations when small samples are used. The results presented in this article include all pediatric hospitals, and therefore, the overall prevalence rate of PrUs in the German speaking part of Switzerland is demonstrated. Data were collected by nurses working at their respective hospitals, which may have caused bias. It was made clear to participants, however, that this study was not used to evaluate their work, or their institution, so there were no positive or negative incentives to make the results positive or negative. This study shows that severe PrUs occur especially in older pediatric patients (98 years old) with chronic conditions and/or after surgical interventions. It is of great importance to assess these patients carefully for their risk of PrU development, and healthcare professionals need to be aware of these high-risk patients. For pediatric patients, no research-based wound care guidelines are available, and wound dressings are often not tested in different pediatric populations, such as neonates, infants, and children. The authors identified only earlier studies about NPWT use and surgical techniques in pediatric patients, which provide some research-based information about PrU treatment in pediatric patients. As already noted, specific wound care guidance with regard to different age groups in pediatric patients is of great importance. Further research in this area is therefore crucial, as well as research to obtain more evidence for the different types of wound dressings in children with PrUs.

CONCLUSIONS AND IMPLICATIONS FOR CLINICAL PRACTICE To the authors’ knowledge, this is the first time data on the treatment of PrUs in pediatric patients are presented. Most of

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the PrUs in these hospitalized pediatric patients are category 1. Therefore, appropriate preventive interventions to avoid any further trauma or worsening of these patients’ PrUs are mandatory. Severe PrUs of categories 2, 3, and 4 are mostly limited to older pediatric (98 years old) patients, especially with chronic conditions or after surgical, especially orthopedic, interventions. In addition, there is an explicit need for an evidence-based pediatric-specific guideline regarding the treatment of PrUs. It is a clinical challenge to use dressings, which are appropriate both to the goal that has to be achieved in wound healing and to specific pediatric needs. The choice of a dressing in children with PrUs should be balanced, well documented, and regularly evaluated. Pediatric patients are not small adults; this needs to be recognized when providing wound care.

&

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Pressure ulcer treatment in pediatric patients.

To assess pressure ulcer (PrU) treatment in Swiss hospitalized pediatric patients and to determine whether there are differences in PrU treatment, acc...
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