17.3 Pediatric Wound Care
Key Takeaways
- Infant skin, especially in premature infants, has an immature barrier and a high surface-area-to-weight ratio, so topical agents are absorbed more; povidone-iodine can cause hypothyroidism, alcohol and chlorhexidine can cause chemical burns in preterm infants, and silver sulfadiazine is avoided in newborns under 2 months.
- Pediatric pressure injuries are often device-related (masks, tubing, probes, splints), and in infants the occiput is a common site because the head is large relative to the body.
- Epidermolysis bullosa is a genetic blistering disorder (simplex, junctional, dystrophic, and Kindler types); care uses nonadherent silicone dressings, lancing new blisters while keeping the roof, and no adhesives, and FDA-approved therapies include topical beremagene geperpavec (2023), birch triterpenes gel (2023), and prademagene zamikeracel gene-corrected grafts (2025).
- Child burns differ from adult burns: use the Lund-Browder chart or a pediatric rule of nines because the head is proportionally larger, resuscitate with about 3 mL/kg/%TBSA plus maintenance glucose-containing fluid in young children, and look for abuse patterns such as sharply demarcated symmetric immersion burns.
- Suspected child abuse must be reported under state mandatory reporting laws, and pediatric care decisions involve parents or guardians with the child's assent when developmentally appropriate.
17.3 Pediatric Wound Care
Core Clinical Principle: Children are not small adults. Their skin absorbs topical agents more readily, their pressure injuries come from different sources, their burns are estimated differently, and some wounds signal genetic disease or abuse. Safe pediatric wound care adapts products, tools, and communication to the child's age and development.
The CWSP outline lists pediatric issues under Etiological Considerations. This section focuses on the differences that change wound care decisions.
Neonatal and Infant Skin
- Barrier immaturity: Premature infants have a thin stratum corneum and high transepidermal water loss; barrier function matures over the first weeks after birth.
- Absorption: A large surface-area-to-weight ratio increases systemic absorption of topical products.
- Weak dermal-epidermal attachment: Adhesive removal easily strips the epidermis.
| Product | Pediatric Concern | Safer Approach |
|---|---|---|
| Povidone-iodine | Iodine absorption can cause transient hypothyroidism in neonates | Limit area and duration; remove after use |
| Chlorhexidine | Irritation and chemical burns in premature infants and infants under 2 months (FDA labeling caution) | Use with care, lowest effective concentration, remove residue |
| Isopropyl alcohol | Chemical burns under occlusion in preterm infants | Avoid prolonged contact or pooling |
| Silver sulfadiazine | Kernicterus risk in newborns | Avoid in infants under 2 months |
| Lidocaine-prilocaine cream | Methemoglobinemia in young infants, especially with other oxidizing drugs | Follow age and dose limits |
| Neomycin, salicylic acid, high-potency steroids | Toxicity or systemic effects from absorption | Avoid or use sparingly |
| Adhesives and removers | Epidermal stripping; solvent toxicity | Silicone adhesives, minimal tape, water or silicone-based removal |
Pressure and Device Injuries in Children
- Medical devices cause a large share of pediatric pressure injuries: nasal CPAP masks and prongs, endotracheal tubes, pulse oximeter probes, arterial line hubs, cervical collars, splints, and casts.
- Location: In infants and toddlers, the occiput is a common site because the head is large and heavy relative to the body; older children develop sacral and heel injuries like adults.
- Risk tools: Use pediatric scales such as the Braden QD, which counts medical devices and repositionability.
- Prevention: Pad and rotate device sites, check under devices at least twice daily, use gel pillows for the occiput, and size devices correctly.
Other Common Pediatric Wounds
- Peripheral IV infiltration and extravasation: Common in neonates; stop the infusion, elevate, and use hyaluronidase for many hyperosmolar or irritant solutions (such as calcium, dextrose above 10%, and parenteral nutrition) according to protocol; photograph and monitor for blistering and necrosis.
- Diaper dermatitis: Irritant dermatitis sparing the skin folds; candidal dermatitis involves the folds with satellite lesions. Treat with frequent changes, zinc oxide or petrolatum barriers, and antifungals when Candida is present.
- Ulcerated infantile hemangiomas: Ulceration is the most common complication, often in the diaper area or lip, and is very painful. Treat with barrier ointments, nonadherent dressings, pain control, and systemic propranolol (the first-line treatment for hemangiomas needing therapy), with pediatric dermatology guidance.
- Pilonidal disease: Common in adolescents; wounds after excision often heal by secondary intention.
- Spina bifida and spinal cord conditions: Insensate skin leads to pressure injuries and neuropathic foot ulcers; many patients have latex allergy, so use latex-free supplies.
Epidermolysis Bullosa (EB)
| Major Type | Level of Blistering | Examples of Affected Proteins | Features |
|---|---|---|---|
| EB simplex | Within basal keratinocytes | Keratin 5 and 14 | Usually milder; blisters on hands and feet |
| Junctional EB | Lamina lucida | Laminin-332, type XVII collagen | Can be severe and fatal in infancy; chronic wounds, dental enamel defects |
| Dystrophic EB | Below the lamina densa | Type VII collagen | Scarring, "mitten" fusion of fingers, esophageal strictures, high risk of aggressive squamous cell carcinoma |
| Kindler EB | Mixed levels | Kindlin-1 | Blistering, photosensitivity, poikiloderma |
Wound care principles:
- Lance new blisters with a sterile needle to stop them spreading, and leave the roof as a protective cover.
- Use nonadherent silicone contact layers and foams, secure dressings with tubular bandages or wraps, and never use adhesive tape on skin.
- Lift infants by rolling onto a soft surface rather than under the arms, and pad all surfaces.
- Manage pain, itch, infection, anemia, nutrition, and growth with a multidisciplinary EB team.
- FDA-approved therapies: topical beremagene geperpavec gene therapy for dystrophic EB wounds (May 2023), birch triterpenes topical gel for junctional and dystrophic EB wounds (December 2023), and prademagene zamikeracel, gene-corrected autologous keratinocyte sheets for recessive dystrophic EB wounds (April 2025).
- Biopsy chronic nonhealing wounds in dystrophic EB to look for squamous cell carcinoma.
Pediatric Burns
- Body surface area: An infant's head and neck represent roughly 18% or more of body surface area and each leg less than an adult's 18%, so use the Lund-Browder chart or a pediatric rule of nines. The child's palm with fingers is about 1% TBSA.
- Resuscitation: ATLS suggests starting at about 3 mL/kg/%TBSA for children, plus maintenance fluid containing glucose for small children, titrated to urine output of about 1 mL/kg/h in children weighing 30 kg or less.
- Scalds are the most common burns in young children.
Recognizing Abuse
| Pattern | Concern |
|---|---|
| Immersion burns with sharp "stocking" or "glove" borders, uniform depth, symmetry, and no splash marks; spared flexion creases or buttock center ("doughnut" sign) | Forced immersion in hot water |
| Round burns about 7 to 10 mm across | Cigarette burns |
| Patterned burns (iron, grill, curling iron) | Contact with a hot object held against skin |
| History that does not match the injury or the child's developmental ability, or delayed care | Possible abuse or neglect |
Clinicians are mandated reporters of suspected child abuse under state law; document objectively with measurements and photographs, and involve child protection teams.
Consent, Assent, and Family-Centered Care
Parents or legal guardians give informed permission for treatment, and children should give assent when developmentally able (commonly from about age 7). Some adolescents can consent for themselves under state law (for example, emancipated or mature minors). Involve the family in dressing changes, use distraction and child life specialists for procedures, and plan pain control before painful care.
Clinical Traps
Trap 1: Using Adult Antiseptic Habits in the NICU
Generous povidone-iodine or alcohol under occlusion in a preterm infant can cause chemical burns or thyroid suppression. Use minimal amounts and remove residue.
Trap 2: Taping a Dressing on a Child With EB
Adhesive tape on EB skin creates new wounds when removed. Use wraps, tubular retention bandages, and silicone products.
A neonatal intensive care nurse is preparing skin antisepsis for a peripheral line in a 27-week premature infant who is 5 days old. Which approach best reflects pediatric skin safety principles?
A 3-week-old infant with recessive dystrophic epidermolysis bullosa has several new tense blisters on the feet and hands. Which wound care plan is most appropriate?
A 2-year-old is brought for care of burns to both feet. The caregiver says the child climbed into the bathtub alone. Both feet have full-thickness burns of uniform depth ending in sharp, straight lines at the same level above the ankles, with no splash marks, and the child has an older healing burn on the buttock. What is the most appropriate response?