In July 1998, the National Institutes of Health (NIH) issued a policy guidance statement that children must be included in all human subject research conducted or supported by NIH unless there are scientific and ethical reasons not to include them. 1 NIH defines children as individuals under the age of 21. Prior to the NIH policy statement, children were routinely excluded from pressure ulcer (PU) research because PUs were believed to occur infrequently in this population. Data to support this belief were scarce. If it were true, however, including children in PU research studies with adults might prove to be of little value in determining best-practice models for preventing and managing PUs in children. These children would comprise such a small segment of a larger study with adults that the results of the research might not be applicable to them.
A national study using a questionnaire was planned to learn more about incidence and prevalence of pressure ulcers in children. An intensive review of the literature was first undertaken to collect any published data on this subject.
Since 1972, 22 articles have been published about pediatric PUs. Five articles were published in British nursing journals and yielded no information about incidence and prevalence data in the United States. 2–6 Waterlow 6 cited differences in pediatric and adult skin when she concluded that her adult risk assessment scale, the most frequently used scale in Britain, was not appropriate for children, especially very young children. All other British articles addressed risk assessment in children.
One Canadian article 7 dealt with pressure necrosis following muscle-free flaps with split-thickness skin grafts. Another article from Finland 8 surveyed all age ranges in 11 health care institutions and found long-term-care institutions had a higher PU incidence. A Japanese dental article 9 discussed oral tissue necrosis following multiple seizures in a 2-year-old child. A German article 10 addressed stump breakdown following traumatic amputation in children. Again, none of these articles provided incidence and prevalence data from the United States.
Authors from the United States wrote the remaining 13 articles. 11–23 The earliest US article 11 found, however, did not mention PUs, but dealt with thermal regulation during pediatric surgery and discussed use of a specialty bed. The first US article mentioning PU development in children 12 was published in 1980 and tested polyurethane moisture-vapor permeable film for the treatment of superficial wounds in children. Three children in the sample had PUs.
Five articles concerned PU development in pediatric intensive care units. 13–17 Three of the articles reported incidence rates of 16.9%15, 24%13, and 26%. 17 Of the remaining 6 articles, 1 studied osteomyelitis with and without wounds but did not mention PUs. 18 Another article addressed skin complications in pediatric bone marrow transplant patients. 19 Three articles described general skin care protocols for PU prevention in pediatric patients. 20–22 The final article measured supine interface pressure in children. 23 The authors reported that the pressure relief devices effective in children were significantly different from those effective for adults. In their study, the highest interface pressures occurred under the occiput in young children and under the sacrum in older children.
The true incidence and prevalence of PUs in children, therefore, is unknown. Although 3 site-specific incident rates have been published, no general incidence or prevalence data could be found in the literature. The prior assumption that PU incidence and prevalence rates in children are small is unsubstantiated, due to the lack of scientific studies to determine those rates.
A national survey of children’s health care institutions was conducted to determine the incidence and prevalence of PUs in children. Institutions surveyed were members of 1 of 4 Internet databases: the National Association of Children’s Hospitals and Related Institutions, the Children’s Miracle Network, Shriner’s Hospitals, and Scottish Rite Hospitals. It was impossible to accurately determine from those lists which institutions provided inpatient medical care, specialty care, outpatient care, or in-home care, or which treated physical problems and which treated psychological problems. Therefore, questionnaires were mailed to all institutions.
A total of 224 questionnaires were mailed throughout all 50 states. The questionnaire asked for (1) the number of currently occupied pediatric beds, (2) annual pediatric admissions, (3) children currently hospitalized with PUs, and (4) the number of children who were admitted with or developed PUs in 1998. Demographic data (age, admitting diagnosis, and PU stage and location) were requested for those children who developed PUs in 1998.
A total of 55 questionnaires were returned for a response rate of 25%. Although the response rate was low, many of the facilities to which questionnaires were mailed may not have treated inpatients.
Of the 55 questionnaires returned, 51 were suitable for calculating prevalence data. Four could not be included because the respondents either refused to provide data (2), mixed adult and pediatric data (1), or provided child psychiatric services (1). Forty of the 51 returned questionnaires were suitable for calculating incidence data. Eleven could not be included because they did not track PU data in 1998 (6) or gave average daily census instead of total pediatric admissions (5).
Of the sample of 4,429 pediatric patients who were hospitalized at the time of data collection, 21 patients had PUs, for a PU prevalence rate of 0.47% (95% confidence interval [CI] = -0.0027 to 0.0067). Of the sample of 115,870 pediatric patients admitted in 1998, 337 patients had documented PU development, for an incidence rate of 0.29% (95% CI = 0.002899953 to 0.002900047;Table 1).
Not all agencies that responded gave complete demographic data. For those agencies that did, patients ranged in age from 1 month to 21 years, the nationally accepted pediatric exit point for children with chronic disabilities. Children with disabilities are treated in pediatric facilities until the age of 21, when they become part of the adult health care system. Children who were aged 10 and under developed 47% of PUs. Children who were over the age of 10 developed 53% of PUs (Table 2). Children with chronic or terminal illnesses developed 75% of the documented PUs. Pediatric victims of accidental injury developed 25% of PUs (Table 3). Stage II PUs were documented most frequently (Table 4).
The sacrum/coccyx was the most frequent site for PUs, accounting for 40% of below-the-waist PUs (Table 5). Heels were the second most frequent site, accounting for 27% of below-the-waist PUs. Twenty-eight percent of PUs occurred above the waist; the occiput was the site of 65% of these PUs.
Overall incidence and prevalence of PUs in adults had been found to be as high as 29.5%24 —and even higher in specific subgroups of patients. Overall PU prevalence in hospitalized adults in 1997 was reported to be 10.1%. 25 When compared with adult values, PU incidence and prevalence in hospitalized children is significantly lower.
The NIH policy provides several justifications for excluding children from research. The PU incidence and prevalence rates found in children in this national study show that children can be excluded from adult PU research because a separate age-specific study in children is warranted and preferable due to the relative rarity of the condition in children compared with adults (Exclusion 4-a). 1
When comparing data collected on hospitalized children in this study with existing data on hospitalized adults, several similarities are apparent. Most PUs in children occurred below the waist, in the pelvic girdle, the same as in adults. The most frequent site below the waist, the sacrum/coccyx, is also the most frequent site for PU development in adults. The most frequent PU site above the waist was the occiput, a frequent site of PUs in adults as well. Some of the same factors implicated in PU development in adults were also implicated in PU development in children: sedation, hypotension, sepsis, head injury, spinal cord injury, traction devices, and end-stage disease. Spina bifida, the only pediatric-specific factor cited in the demographics, was cited by many facilities as the primary reason for PUs in their pediatric population.
The mechanism of PU formation in the youngest member of the sample to develop a PU, a 1-month-old child, sounded surprisingly like an all-too-frequent scenario in older adults. The PU developed following a prolonged period on an operating room table during open-heart surgery and an unstable post-operative period, during which physiologic instability prohibited turning.
This study had several limitations. The survey response rate was low (25%). Pediatric institutions not listed on the Internet were not surveyed and data on children living in the community with PUs were not captured. Even though PUs did occur, 11 facilities could not supply incidence data for 1998 because PUs were so infrequent in children that data about them were not tracked. In addition, some institutions were reluctant to disclose the requested data.
IMPLICATIONS FOR PRACTICE
Although an infrequent problem in most pediatric institutions, PUs do occur in children. Current treatment of PUs in children is based on product research with samples that do not include children. Because PUs in children are so rare and research or case reports on efficacious treatment is lacking, the best course of care for pediatric PUs is unknown at this time.
The low incidence and prevalence of PUs in pediatric patients indicated that children should not be included in PU studies with adults. However, PU development in pediatric patients is understudied at the present time and separate pediatric-specific studies should be conducted to determine risk factors, best preventive strategies, and the most effective treatments for PUs in this population. All pediatric facilities should track PU data and that data should be pooled among institutions and evaluated so that best-practice models of care in this group can be determined.
1. National Institutes of Health. Policy Guidance on the Inclusion of Children in Research. (online) Available at: http://www.nih.gov/grants/notice-files/not98-024.html
. Accessed July 1998.
2. Bedi A. A tool to fill the gap. Developing a wound risk assessment chart for children. Prof Nurs 1993; 9:112–20.
3. Pickersgill J. Taking the pressure off. Paediatr Nurs 1997; 9( 8):25–7.
4. Waterlow JA. Pressure sore risk assessment in children. Paediatr Nurs 1997; 9( 6):21–4.
5. Crockett A. Paediatric pressure sore risk assessment. J Tissue Viability 1998; 8:30.
6. Olding L, Patterson J. Growing concerns. Nurs Times 1998; 94( 38):74,77–9.
7. Harris PG, Letrosne E, Caouette-Laberge L, Egerszegi EP. Long-term follow-up of coverage of weight bearing surface of the foot with free muscular flap in a pediatric population. Microsurgery 1994; 15:424–9.
8. Lepisto M, Eriksson E, Hietanen H, Asko-Seljavaara S. Prevention of pressure ulcers in acute and long-term care facilities in Finland: results of a survey. Ostomy Wound Manage 2000; 46:30–4.
9. Kozai K, Okamoto M, Nagasaka M. New tongue protector to prevent decubital lingual ulcers caused by tongue thrust with myoclonus. ASDC J Dent Child 1998; 65:474–7.
10. Vocke AK, Schmid A. Osseous overgrowth after post-traumatic amputation of the lower extremity in childhood. Arch Orthop Trauma Surg 2000; 120:452–4.
11. Russell HE, Othersen HB, Hargest TS. Thermal regulation of pediatric patients in the operating room by means of an air fluidized bed. Am Surg 1972; 38:111–14.
12. Lobe TE, Anderson GF, King DR, Boles ET. An improved method of wound management for pediatric patients. J Pediatr Surg 1980; 15:886–9.
13. Riggs CD, Lister G. Adverse occurrences in the pediatric intensive care unit. Pediatr Clin North Am 1987; 34:93–117.
14. Neidig JR, Kleiber C, Oppliger RA. Risk factors associated with pressure ulcers in the pediatric patient following open-heart surgery. Prog Cardiovasc Nurs 1989; 4:99–106.
15. Zollo MB, Gostisha ML, Berens RJ, Schmidt JE, Weigle CG. Altered skin integrity in children admitted to a pediatric intensive care unit. J Nurs Care Qual 1996; 11:62–7.
16. Garvin G. Wound and skin care for the PICU. Crit Care Nurs Q 1997; 20:62–71.
17. Curley MA, Thompson JE, Arnold JH. The effects of early and repeated prone positioning in pediatric patients with acute lung injury. Chest 2000; 118:156–63.
18. Dubey L, Krasinski K, Hernanz-Schulman M. Osteomyelitis secondary to trauma or infected contiguous soft tissue. Pediatr Infect Dis J 1988; 7:26–34.
19. Abramowitz LZ, Baache B. Management of skin care complications in pediatric bone marrow transplant patients: a nursing challenge. J Assoc Pediatr Onco Nurses 1988; 5:37.
20. Hagelgans NA. Pediatric skin care issues for the home care nurse. Pediatr Nurs 1993; 19:499–507.
21. Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs 1996; 1:7–18.
22. Pallija G, Mondozzi M, Webb AA. Skin care of the pediatric patient. J Pediatr Nurs 1999; 14:80–7.
23. Solis I, Krouskop T, Trainer N, Marburger R. Supine interface pressure in children. Arch Phys Med Rehabil 1988; 69:524–6.
24. Clark M, Kadhom, HM. The nursing prevention of pressure sores in hospital and community patients. J Adv Nurs 1998; 13:365–73.
25. Barzak CA, Barnett RI, Childs EJ, Bosley LM. Fourth national pressure ulcer survey. Adv Wound Care 1997; 10:( 4)8–25.
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