Overview
Definition:
Wound care in children encompasses the assessment, cleaning, management, and dressing of skin and soft tissue injuries
It aims to promote healing, prevent infection, minimize scarring, and ensure the child's comfort and well-being
Dressings are crucial for providing a protective barrier, managing exudate, and creating an optimal healing environment.
Epidemiology:
Wounds are common in children, with lacerations, abrasions, and contusions being the most frequent
Burns also represent a significant proportion of pediatric injuries requiring wound care
The incidence varies by age, activity level, and environmental factors
Neonatal skin also requires specialized wound care for conditions like omphalitis or surgical sites.
Clinical Significance:
Effective wound care in children is vital for preventing complications such as infection, delayed healing, hypertrophic scarring, and keloid formation
Proper dressing selection can significantly impact healing time, pain perception, and the cosmetic outcome, which is particularly important in pediatric patients
Understanding age-specific considerations is paramount for appropriate management.
Age Considerations
Neonatal Wounds:
Delicate skin requires gentle handling
Focus on maintaining asepsis
Common issues include umbilical stump care, circumcision site care, and surgical wound management.
Infantile Wounds:
Increased risk of aspiration during cleaning
Diaper dermatitis can complicate wound healing
Parental education is key for home care.
Childhood Wounds:
Higher incidence of abrasions, lacerations from falls and play
Increased risk of contamination
Topical antibiotics often used
Pain management is critical.
Adolescent Wounds:
Similar to adults but with considerations for rapid growth and potential for psychosocial impact of scarring
Acne-related wounds and surgical scars from congenital conditions are relevant.
Clinical Presentation
General Features:
Redness (erythema) around the wound
Swelling (edema)
Warmth to touch
Pain or tenderness
Presence of exudate (serous, purulent).
Signs Of Infection:
Increased erythema extending beyond the wound margins
Purulent discharge with foul odor
Fever or systemic symptoms
Increased pain and swelling
Delayed healing
Cellulitis or lymphangitis.
Wound Assessment:
Location, size, depth, and shape of the wound
Presence of foreign bodies
Underlying structures involved (e.g., tendons, nerves, bones)
Wound bed characteristics (granulation, slough, necrotic tissue)
Exudate amount and type
Signs of infection
Pain level.
Diagnostic Approach
History Taking:
Mechanism of injury (e.g., fall, animal bite, burn)
Time of injury
Contamination level
Tetanus immunization status
Previous wound care or infections
Allergies (especially to topical agents)
Underlying medical conditions.
Physical Examination:
Thorough examination of the wound and surrounding skin
Assessment for signs of infection, ischemia, or injury to deeper structures
Palpation for crepitus
Assessment of distal pulses and sensation if limb injury.
Investigations:
Wound cultures if infection is suspected (swab or tissue biopsy)
Blood tests (CBC, ESR) for systemic infection
Imaging (X-ray, Ultrasound) to detect foreign bodies or underlying bone/joint involvement
Imaging is typically reserved for deeper or complex wounds.
Differential Diagnosis:
Infected wound vs
sterile inflammation
Abscess formation
Cellulitis
Necrotizing fasciitis (rare but critical)
Insect bites
Allergic reactions
Puncture wounds with retained foreign bodies.
Management
Initial Management:
Irrigation and cleaning with sterile saline or appropriate antiseptic solution (e.g., chlorhexidine for routine cleaning, povidone-iodine cautiously)
Gentle debridement of non-viable tissue and removal of gross contaminants
Hemostasis achieved through pressure or local measures.
Wound Dressing Principles:
Maintain a moist wound environment
Protect the wound from further trauma and contamination
Absorb excess exudate
Provide insulation
Facilitate autolytic debridement
Minimize pain and discomfort
Be cost-effective and easy to apply.
Dressing Selection By Wound Type:
Abrasions: Hydrocolloids, transparent films, hydrogels
Lacerations: Adhesive strips, sutures, staples
covered with non-adherent gauze and tape
Puncture wounds: May require leaving open or loosely packed with gauze
careful monitoring for infection
Burns: Silver sulfadiazine cream for superficial burns, specialized burn dressings (silicone-based, foams) for partial-thickness burns
Surgical incisions: Sterile gauze, adhesive dressings, or specialized post-operative dressings
Infected wounds: Antimicrobial dressings (e.g., silver-impregnated), alginates, or foams with frequent changes.
Pharmacological Management:
Topical antibiotics (e.g., bacitracin, neomycin, polymyxin B) for superficial wounds at risk of infection
Systemic antibiotics if signs of spreading infection or deeper tissue involvement (e.g., amoxicillin, cephalexin, clindamycin for suspected MRSA)
Analgesics (paracetamol, ibuprofen) for pain control
Tetanus prophylaxis if indicated based on immunization history and wound classification.
Specialty Dressings And Materials
Basic Dressings:
Sterile gauze (absorbent, protective)
Non-adherent pads (e.g., Adaptic, Mepitel) for sensitive wounds
Adhesive bandages (plasters) for minor cuts and abrasions.
Advanced Dressings:
Hydrocolloids (moisture-retentive, protective)
Hydrogels (hydrating, good for dry wounds)
Foams (highly absorbent, cushioning)
Alginates (highly absorbent, good for exudative wounds)
Silicone-based dressings (gentle to skin, good for sensitive areas)
Transparent films (allow visualization, good for low exudate)
Antimicrobial dressings (e.g., silver, iodine-impregnated) for infected or high-risk wounds.
Biologics And Specialty Products:
Skin substitutes, negative pressure wound therapy (NPWT) for complex or large defects, enzymatic debridement agents
These are less common in routine pediatric practice but may be used in specialized centers.
Complications
Infection:
Bacterial (Staphylococcus, Streptococcus), fungal
May lead to cellulitis, abscess, osteomyelitis, or sepsis
Signs include increased redness, swelling, pain, purulent discharge, fever.
Delayed Healing:
Caused by poor nutrition, underlying medical conditions, infection, inadequate blood supply, or improper wound care
Can lead to chronic wounds.
Scarring And Contractures:
Hypertrophic scars and keloids are common, especially in predisposed individuals
Contractures can occur with deep burns or extensive tissue loss, affecting mobility and function.
Foreign Body Retention:
Leading to chronic inflammation, infection, or granuloma formation
Common in contaminated wounds like abrasions or puncture wounds.
Key Points
Exam Focus:
Dressing selection based on wound characteristics (exudate, depth, infection)
Tetanus prophylaxis guidelines
Management of common pediatric wounds (lacerations, abrasions, burns, bites)
Signs of wound infection.
Clinical Pearls:
Always assess the wound before dressing
Cleanse wounds gently
Educate parents on home care and signs of complications
Pain management is integral
Consider cosmetic outcome in children
For animal bites, consider prophylaxis against rabies and tetanus.
Common Mistakes:
Over-reliance on one type of dressing
Inadequate wound cleansing or debridement
Failure to recognize or treat infection promptly
Inappropriate use of antiseptics (can be cytotoxic)
Forgetting tetanus immunization status
Ignoring parental concerns.