Nutrition, Skin Integrity, and Pressure Ulcer Healing in Chronically Ill Children: An Overview
Data relevant to the acutely ill pediatric population and pressure ulcers regarding risk, location, prevalence, incidence, and treatment are scant. Baldwin1 conducted a national survey of children’s healthcare institutions, including the National Association of Children’s Hospitals, the Children’s Miracle Network, Shriners Hospitals, and Scottish Rite Hospitals. Of the 224 questionnaires mailed throughout the 50 states, 55 (25%) were returned. Data revealed a pressure ulcer incidence of 0.29% and a prevalence rate of 0.47%. They concluded that children with healthy skin who are well hydrated can heal fairly quickly; pressure ulcers in pediatric patients seem out of the ordinary and due to the low incidence and prevalence in this population, children should not be included in pressure ulcer studies with adults.
Lack of data should not be a deterrent to examining this younger population. Technological advances2 in the past 30 years have dramatically improved survival rates for children with life-threatening conditions caused by congenital anomalies, disease, or injury. Hence, many more children are surviving their circumstances and subsequently living with special care needs.3 Some go home with supportive services while others go to specialized nursing care facilities.
Living in a long-term care facility increases the need for pressure ulcer risk assessment and prevention.4 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. The burden of keeping the physical status stable most often overrides skin integrity.5 Additionally, many healthcare providers may not realize that pediatric patients can be at risk for ulcer development.
In the authors’ experience in their 136-bed long-term care and rehabilitation center for children, the skin often indicates physical status and the potential for systemic decompensation. Compromised skin presents a challenge in metabolically and physically compromised children. Pressure ulcers have been anecdotally described on the heels, sacrum, earlobe, neck, calf, back (related to scoliosis), buttocks, and hips (status post spica cast), over the gibbous (related to spina bifida), and in the popliteal area. These observations are consistent with the findings of Samaniego’s6 1-year, retrospective, exploratory study of young wound clinic patients. Pressure ulcers were found in 50 of 69 children with risk factors that included paralysis and immobility. Also, in a study of 524 patients, infancy to age 10, Okamoto7 found that lesions over the perineum or gibbus appeared more frequently in patients of higher paraplegia (P = 0.05). Together, these studies identified the following risk factors for pediatric pressure ulcers: paralysis, insensate areas, immobility, large head size, kyphoscoliosis, high activity, and age. Additional factors include poor nutrition; decreased sensory perception, tissue perfusion, and tissue oxygenation; and conditions that compromise the skin such as eczema, dermatitis, and maceration caused by excessive moisture. These factors represent potential areas for much-needed research.
Nutrition plays a key role in the prevention and treatment of wounds8 both in children and adults.1 As many as 40% of children with special healthcare needs have been estimated to be at risk for nutrition problems.9 Malnutrition is known to affect wound healing, infection rate, mortality, and morbidity in the adult population1; early identification of children at risk is essential. The purpose of this overview is to explore the general role of nutrition in the chronically ill child and specific nutrition-related concerns in children with or at risk for pressure ulcers.
Nutritional Assessment of Children with Chronic Illness and Special Health Needs
Every child needs a full nutritional and clinical assessment to identify current or future risk for becoming malnourished.10 Nutritional assessment should include anthropometric measurements (weight, length/height, head circumference, body mass index, and skin folds).11 These data subsequently are plotted on growth charts according to age and compared with a normed reference population. Commonly used nationally accepted growth charts are based on measurement data collected by the National Center for Health Statistics. Additional growth charts are available specific to race and for an array of conditions such as trisomy 21 (Down syndrome).9
Growth. Normal growth from birth to adolescence occurs in two distinct patterns. From birth to approximately 2 years, growth is rapid but decelerating. From about 2 years to onset of puberty, growth occurs in consistent annual increments. Typically, an infant increases in length about 30% by age 5 months and >50% by age 1 year. Height at 5 years is about double birth length. Weight increase will follow a curve similar to height – ie, birth weight doubles by 5 months, triples by 1 year, and almost quadruples by 2 years. Between age 2 and 5 years, the annual increments are fairly similar.12 Chronically ill children often do not follow these patterns.
The affect of prematurity. When assessing weight and height of a premature infant, measurements should be adjusted/corrected with consideration to gestational age.13 To calculate, the number of weeks the infant was born prematurely should be subtracted from the actual age. A large proportion of the children at the authors’ facility were born premature; hence, they follow a less typical growth pattern.
Chromosomal and neurological abnormalities. Some conditions that involve abnormalities at the chromosomal level are associated with growth patterns that differ from those of children without chromosomal abnormalities14; it is assumed that these differing growth patterns represent altered growth potential. Examples of conditions related to chromosomal aberrations include Prader-Willi syndrome, Cornelia deLange syndrome, Turner syndrome, and trisomy 21. Children with genetic disorders have the potential for altered growth because the affected metabolic pathways are involved in producing energy or building body tissue.15 A retrospective analysis16 of anthropometric data prospectively collected in children with cerebral palsy showed that, among other factors, ambulatory status may contribute to slow growth. Similarly, the growth of children who are non-ambulatory due to neural tube defects (eg, spin bifida myelomeningocele) may be retarded.17
Because many conditions alter the expected course of childhood growth and development, factors affecting nutrition (eg, digestion, absorption, metabolism, and excretion) may be modified by the inherited or acquired disorders as well as by surgery and medications. Therefore, the message is size does not necessarily reflect nutritional status. Normal growth standards do not apply. The goal for growth is to achieve a “normal” curve along a child’s individualized growth chart.
Measuring growth – anthropometrics. Anthropometrics play an important role in the nutritional assessment of a child. Currently, anthropometrics are assessed using the 2000 Center for Disease Control (CDC) growth charts available http://www.cdc.gov/growthcharts/.
Nelson et al18 found that in children with genetic abnormalities that retard growth and delay development, weight for height or length may be more useful in assessing growth adequacy and nutritional needs than height or weight for age. “Height-age” can be useful in estimating advisable weight when children are at less than the fifth percentile for height. Height-age is the age in which the child’s height would be at the 50th percentile. Advisable weight would be at the 50th percentile weight for that age with a range of 25th to 75th percentile. For example, a teenager with developmental delays and an extensive medical history may have the height-age of a 6 year old; if this adolescent is receiving protein-based nutrition based on his/her chronological age versus height age, the diet may not be meeting his needs.
The use of weight has important limitations as a measure of a child’s nutritional status. Fluids related to edema, hydrocephalus, or other fluid retention anomalies shift and dressings, casts, splints, and skeletal traction may make it difficult to obtain accurate weight measurements, particularly just after injury or surgery.19
General clinical assessment. All patients must receive an individualized clinical assessment that involves general appearance (in context to familial history) and hair, skin, oral mucosa, physical activities, exercise, gastrointestinal symptoms of nutritional deficiencies, and laboratory findings (compared to age-based norms).
Laboratory and clinical investigations may help define nutrition problems more clearly and strengthen the information base for nutrition screening, assessment, and intervention with this population.9 Biochemical data are important information to consider in evaluating overall nutritional status. Anecdotal reports note that establishing a biochemical baseline on children receiving long-term care may become an effective measure in preventing skin compromise.
Radiology studies include but are not limited to modified barium swallow and upper gastrointestinal series. These studies are performed to determine whether children anatomically require oral feeding. Patients may require enteral nutrition due to disease or structural abnormalities – some will remain on enteral feeding indefinitely due to structural deficiencies; others, only until organ maturity rectifies their condition.11
Determining Nutritional Needs
Although many of the principles that apply to children are similar to those used in adults, maintenance of proper nutrition is complicated by the child’s smaller body size, need for continued growth, and lower caloric reserves.20 Again, it is essential to consider the child’s medical history and anthropometric measures (current and previous as available) and establish a baseline. Certain diagnoses may put a child at risk for obesity; others increase risk for being underweight, failing to thrive, or malnourishment. Due to their decreased energy needs, children with spastic cerebral palsy, Prader-Willi’s syndrome, myelomeningocele, and other disorders that limit activity are prone to obesity. Conversely, children with hyperactivity, hypertonia, and athetoid cerebral palsy frequently have greatly increased kilocaloric requirements.18 The assessment of energy and protein needs for children is typically based on the National Research Council Recommended Dietary Allowances (RDA) (available at: www.nap.edu); these vary by age and are based on the needs of the average healthy child. It is not unusual for maintenance energy needs of a child with a specific disorder to be as low as 7 to 9 kcal/cm. The range for a normal child would be approximately double. On the other hand, the caloric needs of a child with a wound or recovering from surgery, trauma, burn or wound may exceed the RDA requirements.21
General energy requirements. The energy needs of chronically ill children depend on the resting metabolic rate, degree of illness, physical activity, Tanner stage, and the need for growth.22 Several formulas15 are used to determine energy requirements in adults and children. The standards are based on measurements of energy expenditure and involve total energy expenditure (TEE), rest energy expenditure (REE), physical activity energy expenditure (PAEE), and diet-induced thermogenesis (DIT). Methods for determining energy requirements vary. The RDA is the standard and is based on the usual intake level sufficient to meet the nutrient requirements of healthy children according to life stage and gender. The RDA does not not factor specific energy variables such as resting state, hypermetabolic states due to injury or surgery, growth delay or acceleration, and genetic disorders into recommended caloric estimates for the general population. Thus, calculating individual energy expenditure yields a better idea of the child’s caloric requirements and can take special healthcare needs and diagnoses into account.21
Briassoulis23 studied 37 postop cardiac surgery patients – children mechanically ventilated who have been diagnosed with sepsis, brain injury, or respiratory failure or who have had a transplant – all admitted to the PICU. He found that predicting energy expenditure by using RDA guidelines or specific formulas grossly overestimates the actual energy expenditure, underscoring the difficulty in matching standard with diagnosis in order to make an accurate energy expenditure determination. However, the study concluded that for patients with acute or chronic illness, measurements of energy expenditure are necessary if disease-specific algorithms are not available but should not be the only indicator of pediatric nutritional status.
Nutritional challenges. Children with chronic disease that impacts digestion such as cystic fibrosis and sickle cell anemia are a special challenge for clinical nutritionist because the children present with small height and weight and less fat and muscle mass. Neonates and children are particularly susceptible to the loss of lean body mass due to higher baseline requirements.24,25
Protein. The provision of adequate dietary protein required to maximize protein synthesis and preserve skeletal muscle protein mass, as well as to facilitate wound healing and the inflammatory response, is the single most important nutritional intervention in ill or postoperative children.22 These children are hypermetabolic and need extra energy in calories and protein to support healing, growth, and development. The activity level of the child also should be considered. A child presenting with paraplegia/immobility/chronic illness versus a child who can ambulate independently or achieve some milestones will have different energy expenditures, growth, and developmental needs.22,23 Protein requirements also should be based on height-age of the child rather than chronological age.18
Oral feeding. If it is determined that oral feedings are necessary to meet nutrition requirements, they will be introduced systematically by a speech therapist.11 Although standard enteral formulas have a fixed amount of each component (calories, fat, vitamin, minerals, carbohydrate, fluids and protein), it is still important to estimate the individual components to confirm that the enteral formula of choice meets the child’s needs.19
Nutrition and Pediatric Pressure Ulcers
Ascertaining nutritional status. Because early intervention can be an effective preventive measure if patients at increased risk for pressure ulcer development are identified,5 children in the authors’ facility receive a preliminary (baseline) nutrition evaluation within 24 hours of admission and a full nutritional assessment within 7 days of admission. Assessment upon an admission is of particular value when historical anthropometric data are not available.
Laboratory tests recommended by the NPUAP for adults are also used as guidelines for pediatric residents (patients) because no specific guidelines for children relevant to pressure ulcers exist: baseline albumin level, metabolic panel, and total blood count. As with adults,26, children identified as at-risk for skin breakdown may benefit from a preliminary prealbumin level as well.
Intrinsic and extrinsic factors affecting tissue tolerance should be assessed.5 Intrinsic factors include deficiencies in protein, vitamins (A, C, and D), calcium, zinc, and copper. An additional intrinsic factor is vitamin B2, which helps maintain healthy skin, especially around mouth, nose, and eyes. Its deficiency is a component of seborrheic dermatitis, delayed wound healing, and tissue repair.24 Children without medical compromise deficient in these intrinsic factors usually present with overt symptoms; children with multiple physical compromise and disability may not present as obviously or their symptoms may be interpreted differently. For example, it has been noted anecdotally that although zinc deficiency can delay pressure ulcer healing, the actual wound may be attributed to lack of appropriate positioning or offloading.
The authors’ suggest testing for vitamin absorption but no evidence to support this protocol is available. However, testing is recommended only as needed in the acute care setting, such as in cases of Ricketts and other vitamin disorders. In some immuno-compromised or metabolically challenged children, the absorption level of such vitamins and whether they are delivered and metabolized appropriately for optimum effectiveness are questioned.11 The visceral proteins in the liver, such as retinol-binding protein, prealbumin, and transferrin, have shorter half-lives than albumin; thus, they are even more sensitive in detecting early nutritional changes. Further laboratory testing may be warranted, but should be assessed on an individual basis.26
Providing nutrition. Each child must have an individualized nutritional care plan pertinent to their specific needs and goals.
Protein. The National Pressure Ulcer Advisory Panel27 suggests protein intake should be assessed for adults; for a child at risk for or presenting with a pressure ulcer, adequate dietary protein is required to maximize protein synthesis, facilitate wound healing and the inflammatory response, and preserve skeletal muscle protein mass.22 The quantity of protein administered should be 3 to 4 g/kg/d for low birth weight infants, 2 to 3 g/kg/d for full-term neonates, and 1.5 g/kg/d for older children.22
Vitamins, minerals, and hydration. Assessment and regulation of the vitamin and mineral status of a malnourished child is essential in the rehabilitation process.26 Also, according to a review of the adult skin requirements,28 hydration status must be considered and addressed; particularly in a special needs population, fluid imbalance is presumed to enhance risk for pressure ulcers. All classic signs of dehydration should be assessed for this determination, not just weight loss; skin turgor, sunken fontanels, and dry mucous membranes should be included.
Facility Skin Care Program
The pressure ulcers encountered in the authors’ facility are mostly related to orthopedic procedures. It takes a team of caregivers to obtain effective outcomes. Maintaining nutrition and intervening when necessary is a key factor, not only in pressure ulcer healing, but also of the plan to avoid compromising the integumentary system in children with special healthcare needs. A skin care program was developed to maintain skin integrity and prevent skin breakdown and involves assessment, treatment, monitoring, maintenance, and pressure ulcer prevention. The program embraces a transdisciplinary team approach. The skin care team comprises all disciplines involved in indirect and direct care (the rehabilitation nurse who coordinates and runs the program; nursing; rehabilitation; child life, nutrition, and medical personnel; and family) and includes seven skin liaisons from each unit. Skin liaisons facilitate communication/consistency/education/policy and protocol building and implementation of program initiatives. The skin liaisons meet once a month with the rehabilitation nurse to promote integumentary integrity in the facility. Feedback involves but is not exclusively limited to pressure ulcers and specific unit concerns. The rehabilitation nurse rounds with the individual units once a week to monitor and observe active pressure ulcers and to provide treatment recommendations and follow-up of skin breakdown.
On admission, the new patient undergoes physical assessment and any skin abnormality or disease process is noted. The skin care team gathers to discuss preventive and maintenance care planning for the child, including optimal nutrition. One goal is to determine/assess for any nutritional deficiencies, food allergies/intolerances, and potential food-drug interactions. Mealtime observation, enteral feeding evaluation, and/or parent/guardian interview are paramount in the gathering of nutritional history and status. At this facility, the children receive rehabilitation service everyday, increasing energy expenditures and requiring attention to protein, which is addressed by the nutritionist. The team shares responsibilities and education focused on prevention and treatment.
Making nutrition an integral part of intervention has played a role in successful healing. A systematic review/meta-analysis,29 along with a randomized controlled trial,30 support enteral nutritional enhancement and/or use of supplemental arginine, vitamin C, and zinc in patients at risk for or presenting with pressure ulcers. Overall, nutrients of focus for the prevention and treatment of pressure ulcers for chronically ill children with special healthcare needs are protein (for growth and repair of cells and to serve as a catalyst in chemical interchange in the body), arginine (promotes collagen synthesis for new skin, increases blood flow to wound, and may help fight off infection), vitamin C (helps prevent free-radical production that can inhibit healing), vitamin A (required for epithelial formation but can be toxic), zinc (required for tissue regeneration and repair but can suppress immune function), copper (has a role in strengthening connective tissue, glutamine (promotes tissue repair), and vitamin B2 (aids wound healing, tissue repair).29,30
Pressure ulcer healing rates at the authors’ facility are within accepted time frames31: projected healing time for the average Stage I pressure ulcer is 14 days; Stage II, 45 days; Stage III, 90 days; and Stage IV, 120 days. The authors believe it takes a village to raise a child and a team to manage a pediatric pressure ulcer or skin breakdown.
The nutritional status of children with special healthcare needs is influenced by a series of complex factors best addressed by interdisciplinary interaction regarding assessment, intervention, maintenance, and prevention. If these factors are not taken into consideration, children will be over- or undernourished, increasing the risk for pressure ulcers and/or compromising healing. No simple formula or algorithm will accurately estimate the requirements for all patients; an initial estimate should be obtained and modified depending on the patient’s response. Nutritional care planning for each child must reflect individual medical history, anthropometrics (adjusted as necessary – ie, height-age), biochemical data (if deficient, restore), and radiologic assessment (if applicable). Quality and tolerance evaluation of both oral and enteral intake, texture, self-feeding level, history of feeding, caloric/ nutrient intake, laboratory baseline findings, pertinent radiography studies, anthropometric history if available, and medications all must be considered in creating a nutrition plan.
Once implemented, the plan should be assessed periodically across the life span according to the patient’s developmental stages and growth, data methodically acquired to determine nutritional status, and baselines created at each stage or change in health status. For a child at risk for pressure ulcers, adequate protein intake is essential, determined by height-for-age calculations and energy expenditure. A child recovering from surgery or with a wound, trauma, or burn may exceed the RDA standards due to the increased energy expenditure of recovery.
One facility’s care program has heightened awareness through education and communication between caregivers in addition to increasing opportunity to tailor care/nutrition plans (amended from adult/”normal” child criteria and according to experience) to the individual child according specific needs. It is hoped that similar efforts in other institutions will create opportunity for research in the area of pediatric pressure ulcer healing.
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