As the general body of clinical research grows, systematic reviews (SRs) are quickly becoming the only efficient means of remaining up-to-date with shifting standards within any given field of medical practice.1 Tools such as PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess systematic Reviews) are used to assess and ensure the quality and validity of SRs and their clinically significant key points, but there is no guarantee a relevant SR is available.1,2 An attempt to review and update our institution's existing practice guidelines on pediatric wound care was significantly impeded by the lack of high-quality quantitative and qualitative literature available.
Pediatric wound care research is a growing focus within plastic surgery as providers increasingly recognize the very real risk of neonatal and pediatric pressure injury (PI) for patients aged 0 to 17 years. However, pediatric wound care is not a new issue; studies in this topic have been ongoing for more than 20 years,3 and yet a literature search of PubMed, Academic Search Complete (EBSCOhost), Cochrane, and MEDLINE databases spanning a 10-year time frame from January 2009 to December 2019 returned only eight relevant SRs when using a combination of the following keywords: "pressure ulcers", "pressure injuries", "surgical wounds", "epidermal stripping", "intravenous extravasation injuries", "moisture-associated skin damage", OR "advanced wound therapy" (see Figure 1 for literature search). Of the eight studies, the majority do not discuss management, instead focusing on PI characteristics and prevalence (37.5%, n = 3), risk assessment tools (12.5%, n = 1), or prevention bundle implementation (12.5%, n = 1). Of the remaining three articles, one describes the use of medical-grade honey as a pediatric wound dressing. Thus, only two SRs truly discuss PI management. Further, the majority of SRs (62.5%, n = 5) incorporate data from fewer than 20 studies. Across the board, several failed to appropriately report and synthesize results, account for reporting or publication bias, and/or fully list references, further limiting the reports' usability by readers.
Considerations regarding the care and treatment of wounds in the pediatric population are very different from those seen in adult patients. Because of skin immaturity and body size, children under age 2 are considered especially vulnerable to developing PIs.3-5 Children under 5 years are more prone than adults to developing occiput PIs because of their proportionally larger and heavier heads.3 Infant skin properties even differ depending on gestational age, such as increased water loss among infants born at 32 weeks gestation or younger3-a complexity not generally considered for adult patient care. Attempts have been made to adapt findings learned from adult studies to fit the neonate population,6 but the demonstrated physiologic and anatomic differences between pediatric and adult patients emphasize the need for specifically tailored management protocols.
Our brief analysis emphasizes the dearth of high-quality research pertaining to pediatric wound care and points to an urgent need for both increased research activity and greater standardization within this area. It is paramount that high-quality research be made accessible to maintain a high standard of care for this vulnerable patient population. The current lack of comprehensive, injury-specific pediatric guidelines for conditions such as PIs, surgical wounds, epidermal stripping, extravasation injuries, and moisture-associated skin damage creates a risk to both patient care and hospital finances.
CONCLUSION
Failure to effectively advance clinical knowledge will continue to contribute to the ongoing lack of evidence-based guidelines for treatment of pediatric wounds. Going forward, our institution is working toward a solution to this knowledge gap by partnering with industry specialists to create a database of objective measurements and outcomes that can ultimately be used to formulate informed, pediatric wound care guidelines.
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