Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review

Abstract

Objective: Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously. Method: Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included ‘wound care’, ‘wound management’, ‘paediatrics’, ‘children’, ‘skin substitutes’, and ‘grafts’. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: ‘Apligraf’, ‘dermagraft’, ‘Manuka honey’, ‘antibiotic’, ‘timolol’, and ‘negative pressure wound therapy’ (NPWT). Results: Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount. Conclusion: Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.

Necrobiosis lipoidica in childhood: a review of literature with emphasis on therapy

“…Apligraf is a bioengineered wound dressing containing fibroblasts, proteins such as type 1 collagen, and matrix proteins that can serve as a skin substitute 21 . While bioengineered skin matrixes may reduce healing time in chronic ulcers, they have not been sufficiently studied in pediatric patients and they have no major anti‐inflammatory properties, making them a less favorable treatment option for NL 44 …”

Management of wounds with exposed bone structures using an induced‐membrane followed by polymethyl methacrylate and second‐stage skin grafting in the elderly with a 3‐year follow‐up

“…Although negative pressure wound therapy is a well‐established method to promote wound healing and its efficacy is well accepted by many clinicians, it is often used as a bridging device for the closure of a skin graft or skin flap. 24 , 25 Therefore, the formation of vascularised granulation tissue on the exposed areas may be slower, which can be a burden on patients.…”

“…Neo‐vascularisation induced by decorticating the bone or drilling multiple holes into the medullary cavity, for instance, is unreliable and the extent of vascularised bed growth unpredictable, with an inadequate bed possibly causing severe disabilities due to the need to resect functional bone or tendon postoperatively. Although negative pressure wound therapy is a well‐established method to promote wound healing and its efficacy is well accepted by many clinicians, it is often used as a bridging device for the closure of a skin graft or skin flap 24,25 . Therefore, the formation of vascularised granulation tissue on the exposed areas may be slower, which can be a burden on patients.…”

“…Although negative pressure wound therapy is a well-established method to promote wound healing and its efficacy is well accepted by many clinicians, it is often used as a bridging device for the closure of a skin graft or skin flap. 24,25 Therefore, the formation of vascularised granulation tissue on the exposed areas may be slower, which can be a burden on patients. In this study, the angiogenic potential of the IM surrounding the PMMA cement 26 was exploited in combination with skin grafting to repair exposed open wounds in patients with injuries resulting in exposed bone or tendon wounds with a periosteal defect.…”

Meeting the Challenges in Pediatric Wound Care: Our 15-Year Experience with Dialkylcarbamoyl Chloride-Coated Dressing Technology in Acute and Chronic Wounds

“…52 However, there are physiological differences in pediatric skin that affect wound healing and require consideration during treatment. 53 Most wound dressings are developed from adult research studies, and in many cases pediatric wound care specialists must adapt these products for use in children. 49 Wound dressings do not come in small enough sizes for easy use on pediatric patients.…”