Pediatrics care often lacks research evidence to guide many practices. The clinician will look to literature on adults who have had a similar medical diagnosis for guidance. The field of pediatric wound, ostomy and continence (WOC) care is no exception. This lack of evidence supports the theory that innovations and clinical expertise has assisted in guiding practice — that especially in pediatric care, “art” is as important as “science.”
Wound care. In 2006, I became the first WOC nurse at a large Midwest pediatric hospital. I was tasked with preventing pressure injuries. Searching the literature for prevention measures was an exercise in futility. I contacted one of the creators of the Braden Q Risk Assessment Score and asked about prevention measures; unfortunately, no specific interventions were attached to the subscales. As the hospital’s team started to collect data on pressure injuries, it became painfully clear the majority were medical device-related. With no evidence-based guidance available, I innovated. I used a soft silicone dressing that could be cut to size under tracheostomy tubes, gastrostomies, intravenous hubs, and the like and padded any medical device that was unable to be moved. This one innovation decreased our pressure injury prevalence rate by more than 50%.
Although it is commonly thought that “children heal fast,” our young patients can have stalled and desiccated wounds that do not progress to healing without intervention. Wounds need a moist environment to heal; children have a fast metabolism that can put them at risk for dehydration during times of illness. Appropriate products such as hydrogels can help keep wounds moist, but with certain caveats. Glycerin-based hydrogels can dry out, leaving what appears as a piece of plastic, further desiccating the wound. Amorphous hydrogels are absorbed quickly, requiring the nursing staff to apply them several times a day. To address these issues, I use packing gauze (usually antimicrobial dressing), moisten it with normal saline, remove any excess saline, and apply the amorphous hydrogel to the gauze. We apply this to the wound bed and cover it with a soft silicone dressing. This “combination dressing” provides antimicrobial coverage and allows the wound bed to absorb the moisture.
Ostomy care. Ostomy care for our little ones also requires creativity. We have 2 opposing forces working against us with regard to these patients: skin that may not be fully developed and acidic stool. A large majority of our pediatric ostomies are created due to necrotizing enterocolitis that results in short gut syndrome, anorectal malformation, and Hirschsprung’s disease. In order to pouch the ileostomy, we need a barrier that will protect the developing skin and not break down. It is not uncommon for pouches to be changed 3 to 4 times daily because the stool has deteriorated the barrier and using a stoma paste does not increase wear time. The acidity of the stool quickly breaks down the developing skin. On advice from a parent, my colleague started using 2 barriers around the stoma with a 2-piece pouch. The top barrier erodes leaving a plastic covering to protect the second barrier. This practice has increased wear time to 24 to 48 hours.
Repurposing devices. An infant with osteo imperfecta must be handled with extreme care to prevent bone breakage. No product has been designed specifically to accommodate a parent’s desire/need to hold their child. Our staff came up with the idea to use a heel boot designed for adults. The infant was able to be cradled in the boot with her feet offloaded on the end that would have supported the plantar aspect of the adult foot, and her body was securely positioned inside the boot. The parents were able to protect their child and still hold her, creating a satisfying experience for all.
These are but a few examples of how pediatric WOC clinicians rely on creativity in their practice to heal and protect those we serve. I invite you to share your innovations with me and our readers for the benefit of the babies.