Nutrition 411: Children with Wounds: The Importance of Nutrition
Children are not small adults. Rapid growth rate stands at the forefront of distinction in relation to nutritional status. Children are in a constant anabolic state, actively building their bodies. They need more calories, protein, and water per unit of body weight than adults. Often, they are powerless over food choice; parents, caregivers, or teachers decide when and what they eat. Their communication of needs and desires is still developing. Diets, often consisting of unpopular foods restricted by region, ethnicity, and financial or social status, as well as small appetites, are frequently inadequate. Additionally, a child’s adventurous nature spawns risk-taking behavior. Threat of gastrointestinal infection is higher due to exploration and hands-to-mouth gestures. Needs change as rapidly as growth occurs, necessitating flexibility and constant adjustment in plan of care. Nutritional screening, problem prevention, and early intervention are imperative. Attention to unique childhood nutritional needs and requirements is critical to the success of any care plan. Focusing on the provision of optimal nutritional care for support of wound healing is vital to its success.
Incidence of Skin Breakdown in Children
Although the prevalence, prevention, and treatment of skin breakdown in adults have been widely studied, the research in the pediatric population is limited. In 1998, the National Institutes of Health (NIH) mandated that any human research supported by the NIH include attention to children under the age of 21. This elicited study of wound incidence in children, and the literature now indicates that prevalence of wounds in children is high enough to warrant interest.1
Although the exact incidence is currently unknown, skin breakdown and pressure ulcers exist in the pediatric population. Wounds occur in both the hospital and home environments. Wounds may develop in children with chronic illness such as myelomenigocele (spina bifida), cerebral palsy, paraplegia, myelodysplasia, scoliosis, and clubfeet.2 Children who are critically ill with extended hospital stays in the pediatric intensive care unit have higher risk of skin breakdown, which leads to higher risk of mortality.3 Pressure ulcers also develop due to frequent accidental injury, which occurs in children due to their developing physical abilities and poor recognition of dangerous situations. Common types of minor wounds are soft tissue bruising, abrasions, lacerations, puncture wounds, and diaper dermatitis in infants.4 Major sites of skin breakdown in pediatrics differ from those of adults. The most common sites are the occipital region in children <36 months old and the sacral region in older children. In orthopedic injury, skin breakdown occurs more in lower extremities, mostly in the feet. Of additional concern is childhood propensity for developing keloid or hypertrophic scaring due to anabolic state and abundant collagen formation.2 From a positive prospective, children have a great capacity for healing, wounds included. Children suffer from fewer comorbidities such as diabetes or heart disease; thus, they heal at a more rapid rate with fewer complications.
Nutritional Status as Part of Wound Risk Assessment
Risk factors for pressure ulcer development have been well defined in the adult population, but not in the pediatric population. The standard factors of risk assessment used in adults can be applied to children. These include immobility, neurologic impairment, impaired perfusion, decreased oxygenation, poor nutritional status, presence of infection, moisture, acidemia, and weight status.4 Again, it is a mistake to treat children as adults because physical and metabolic differences create other risks. For example, overlooking unique childhood characteristics in pediatric burn patients leads to higher risk of complications.5 First, skin is more fragile and thus provides less of a protective barrier, especially in infants. Second, organ function and the immune system have not yet matured to full capacity, which increases risk of bacterial or secondary infections as well as altered metabolic processes. Third, growth needs coupled with increased needs of illness create a scenario that quickly leads to a catabolic state and subsequent negative nitrogen balance. Children become more susceptible to dehydration and malnutrition, ultimately increasing the risk of skin breakdown.
The Braden Q Scale is a pressure ulcer risk assessment instrument developed for children ages 21 days to 8 years. This tool has been used to provide early and ongoing assessment of risk factors associated with pressure ulcer development. Seven categories are assessed, including mobility, activity, sensory perception, moisture, friction or shear, tissue perfusion or oxygenation, and nutrition.5
The Braden Q scale outlines four levels of nutritional screening based on a child’s usual food pattern (see Table 1).4 Although the role nutrition plays in preventing and managing wounds in the pediatric population has not been studied, evidence exists that hospitalized children with pressure ulcers are also at risk of inadequate nutritional intake.6 Suboptimal nutritional status, whether it is over- or undernutrition, plays an important role in pressure ulcer development and healing. It is clear that a comprehensive pediatric skin care program must include early recognition of nutritionally at-risk infants or children to minimize the complications associated with inadequate nutrition, as well as provide for optimal wound healing. Additionally, ongoing assessment throughout the healing process, including in the outpatient setting whether it is a rehabilitation facility or a child’s home, is equally important to expedite the healing process.
Daily Childhood Nutritional Needs
The rules of childhood nutrition begin with one key principle: Children are born with the ability to regulate intake based on hunger and when allowed to do this from an early age grow appropriately and develop a lifestyle of healthful eating free of risk of becoming overweight. Adults supply healthy food and decide when and what is provided and children decide if they want to eat it or not and how much to eat at a given time. Adhering to this principle holds many challenges for parents and caregivers anxious to ensure children are eating enough. Proper portioning of foods must be based on age and often portions are quite small, especially for infants and young children.
The best way to determine if children are meeting the recommended nutrition requirements is by plotting growth on the National Center for Health Statistics Growth Charts. Both weight and height are plotted and evaluated based on growth curves. Linear growth is the goal, with growth parameters neither falling below nor rising above the normal curve. Nutritional needs for calories and protein are based on age as well as body weight (see Table 2).7
Fluid needs also are based on body weight. Water, an essential component for cellular structures, comprises a higher percentage of body composition in children than in adults. Table 3 shows the formula used to determine fluid needs in children.
Dietary fat is essential in children to support growth and brain development. Although reducing fat in children under 2 years of age is not recommended due to higher needs, it is recognized that a high-fat diet in children older than 2 years of age holds a risk similar to adults. For children 2 years of age and above, fat intake between 20% and 30% of total daily calories is suggested.
Optimal fiber, a critical nutrient and one that is often inadequate, is calculated by adding 5 g to a child’s age for a recommended daily amount. Vitamin and mineral supplementation is not necessary if diet intake and growth are adequate. Children with food allergies, those who regularly omit entire food groups, and those with limited food acceptances are likely candidates for supplementation. Offering a standard pediatric multivitamin is a safe and effective practice and involves no risk of excessive intake.
Special Nutritional Considerations for Wound Management in Children
Feedings, whether oral, enteral, or parenteral, often are inadequate to meet needs associated with wound healing in children. Energy, protein, and vitamin/mineral requirements are elevated to provide for increased energy expenditure, collagen synthesis needed for healing, support of immune function, and increased nutrient losses from the wound itself. Adequate caloric intake is important to spare protein calories for wound healing. Increased protein needs for children age 0 to 6 years are between 3 g and 4.5 g protein per kg body weight. For children 6 years and older, protein needs are increased to 2.5 g to 3 g protein per kg body weight.8 Fluid needs are increased due to higher urinary and insensible water losses from compromised skin barrier. Children are at higher risk for inadequate intake due to small appetites and their already accelerated nutrient needs to support normal growth and development. Suboptimal nutrient intake will delay and complicate the healing process. Nutrients that have key roles in the wound healing process along with dietary sources of the nutrients are outlined in Table 4.9
Challenges to Meeting Nutritional Needs
The challenge of feeding a family starts at the crack of dawn with a hectic morning routine and getting everyone dressed, fed, and out the door on time. Breakfast, lunch, and snacks often are eaten outside of the home. Dinner may be quickly put together at the end of a busy day. It is not surprising that reliance on convenience and prepared foods has become the norm. Healthy eating becomes more stressful when nutritional concerns such as wound healing are an added factor. Children are commonly picky eaters; they may refuse to eat what is offered. Staying positive, calm, and pleasant and continuing to offer a variety of foods on a regular schedule is most effective at dealing with childhood behaviors. Forcing a child to eat will not result in promoting improved eating behaviors. Table 5 outlines common feeding challenges with suggestions for solutions.
Solutions to Nutritional Issues
Energy. Adequate caloric intake is essential to support needs for growth while sparing protein needed for optimal wound healing. Nonprotein calories provided by carbohydrate and fat should comprise the majority of intake, allowing protein use for collagen synthesis. Nutrient-dense calories are an important consideration. Every bite of food must provide nutrients so small stomachs do not fill up on empty calories. The challenge of meeting higher calorie and protein needs requires frequent small meals throughout the day. Five to six small meals will better meet needs than three meals a day. Snacks used as small, nutritious meals can contribute to the success of meeting calorie needs.
Supplements. Often, the challenges of childhood food preferences and small appetites make meeting needs too difficult, necessitating use of nutritional supplements. When suggesting the use of these supplements, cost must be considered. Although a part of medical care, they are not covered by insurance on an outpatient basis unless they provide a majority of nutrition, as in enteral tube feedings. Obtaining approval for supplements from insurance companies requires a letter of medical necessity that includes an assessment of nutritional status completed either by the physician or a registered dietitian (RD), accompanied by documents stating diagnosis and feeding impairments preventing nutritional needs from being met by solid food intake.
Commercial nutritional supplements are convenient for parents and provide a consistent nutrient component. However, being creative with at-home recipes can often supplement intake in the same way and can be individualized to meet a child’s preferences for flavor and consistency. Milkshakes, smoothies, and milk fortifiers can be used. For infants <1 year of age, increasing calories and protein can be accomplished by concentrating infant formula. Infant formula prepared as directed provides 20 calories per ounce. Depending on needs, either liquid concentrate or powdered formula can be mixed to 24 or 27 calories per ounce. After 1 year of age, nutritional supplements specific for children provide 30 calories per ounce or 1 calorie per cc. Supplements that provide 1.5 calories per cc for older children whose intake is severely limited also are available. Providing concentrated calories in this way will provide nutritional needs in a smaller volume and thus prevent satiety before inadequate intake.
Protein. High-protein intake improves wound healing and infection control. There are many ways to optimize protein in a child’s diet. The following suggestions emphasize the use of foods high in protein and that are well accepted by children.
• Serve cheese on toast or with crackers
• Add grated cheese to soup, vegetables, baked potatoes, noodles, chili, or stews
• Make double milk by adding 1 tablespoon of dry milk powder to 8 oz of milk
• Add powdered milk or protein powder to mashed potatoes, macaroni and cheese, gravies, cream soups, or scrambled eggs
• Use half & half, cream, or whole milk instead of water with hot cereal and add additional dry milk powder
Meat and eggs
• Add cooked meats to sauces, soups, omelets, casseroles, and salads
• Add hard-cooked eggs to salads or make egg salad
• Add extra eggs to pancake or waffle batters
• Make a dip with chopped or shredded meats, sour cream, and spices
Beans, nuts, and seeds
• Sprinkle nuts and seeds on salads, cereal, fruit, ice cream, and pudding or add to pasta or vegetables
• Spread peanut butter on toast, crackers, muffins, and fruit or blend into milkshakes
• Add beans and peas to salads, casseroles, soups, or vegetables
• Celery sticks with cream cheese or peanut butter
• Greek yogurt with nuts and berries
• Apples with peanut, almond, or other nut butter
• String cheese
• Animal crackers with cream cheese
• Trail mix made with nuts, cereal, and dried fruit
• Yogurt drinks
• Protein bars
• High-protein milkshakes as snacks such as: 1 cup milk, 1 package instant breakfast, 1 cup whipped cream, 2 tablespoons chocolate, strawberry, or butterscotch syrup or peanut butter. Blend all ingredients at low speed until smooth
• Smoothies prepared with yogurt, fresh or frozen fruits, and milk or juice
• Milk fortification such as “Instant Breakfast” or other protein powders
• Commercial liquid nutritional supplements specifically for the pediatric population
Meals away from home. Eating a meal away from home with other people can be an excellent opportunity for optimizing daily intake. Eating behaviors such as food refusal and pickiness are more pronounced at home where children often manipulate parents as a display of independence. At school, not only are children eating independently, but also the influence of other children often has a positive impact. When a child sees other children eating, he or she is more likely to accept new foods and also eat more. School lunch programs supply nutrient rich foods; however, they may not be readily accepted. Packing a lunch provides opportunity to ensure that nutrient-dense foods are consumed. Even snack items added to the lunch box can contribute significantly to overall daily intake. Nutritional supplements often are allowed at schools as well. If a child does not eat lunch foods such as a sandwich, several high-protein snack options can be sent in lunch boxes along with fresh fruits (see Table 6).
Constipation. Constipation is a common problem in infants and children due to immature digestive systems and underdeveloped intestinal flora. Fiber and fluid intake may be suboptimal, especially if early satiety is occurring. Because they often are not favorites, foods high in fiber are eaten in limited amounts
. Alleviating the discomfort of constipation is critical for a healthy appetite. When adding fiber, it is important to increase amounts slowly to prevent gas and bloating. Whole-grain breads and cereals, legumes, brown rice, oatmeal, and fresh fruits and vegetables are excellent sources of fiber. Adequate water intake can be achieved by offering small amounts frequently throughout the day. Lastly, pear juice or nectar is a highly effective way to soften stools and promote regular bowel movements and is more well tolerated and accepted than prune juice.
The key to nutritional adequacy in children is growth. Monitoring weight gain and growth trends by plotting weight and height on growth charts is the best way to determine growth adequacy. If a child is not growing, he or she is not likely receiving adequate nutrition. This is a problem that needs intervention. Families often benefit from suggestions that will improve oral intake. Even a small change can have a large impact. In the most difficult cases — ie, failure to thrive and a wound not healing — a consultation with an RD specializing in pediatric nutrition is one of the most effective measures to take.10 A thorough nutritional assessment will identify specific deficiencies and allow for individual care plans to be developed. Optimizing nutritional intake has value at all levels of wound management in children beginning with prevention, working through treatment, and ending with successful healing.
Dina Ranade is the Nutrition Program Coordinator for a childcare/preschool program in New Jersey. For the past 21 years, she has served as a pediatric nutri¬tionist in various settings, including neonatal and pediatric intensive care units and the Early Intervention Program. Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.
This article was not subject to the Ostomy Wound Management peer-review process.