INTRODUCTION

Overview

Pediatric wound management presents unique challenges, including limited standardized assessment tools and variability in treatment approaches. These gaps can lead to inconsistent care and product selection. Standardizing assessment and management is essential for improving outcomes and supporting clear clinical decision-making.[1] 

This topic provides a structured framework and evidence-informed guidance for assessing and managing common wounds in the pediatric population.

Background

Definitions

• Pediatric definitions based on age [4][5][6]
• Pediatric: Infancy to 21 years of age.
• Infancy: Birth to 12 months of age.
• Neonatal: Birth to 28 days of age.
• Postneonatal: 28 days of age to 12 months of age.
• Early Childhood: 1 to 6 years of age.
• Toddler: 1 to 3 years of age.
• Preschooler: 3 to 6 years of age.
• Middle Childhood: 6 to 11 years of age.
• Later Childhood: 11 to 19 years of age.
• Prepubertal: 10 to 13 years of age.
• Adolescence: 13 to approximately 18 years of age.
• Definitions based on gestational age upon birth [7]: 
• Premature/Preterm Infants: Born before 37 weeks gestational age.
• Late Preterm Infant: Born between 34 weeks and 36 weeks, 6 days gestation.
• Definitions based on birth weight [8]:
• Low birth weight (LBW): Less than 2,500 grams.
• Very low birth weight (VLBW): Less than 1,500 grams at birth, regardless of gestational age.
• Extremely low birth weight (ELBW): Less than 1,000 grams at birth.

Relevance

• Need for specialized care: Pediatric patients are not simply "mini-adults" and require a specialized approach to care. Key considerations include [1]
• Neonatal and pediatric skin: The thin and underdeveloped skin of premature and neonatal infants is highly susceptible to damage and infection. While skin layers thicken with age, pediatric skin remains generally more vulnerable than adult skin, achieving adult maturity around age 12.[9] 
• See section 'Developmental Considerations of Neonatal and Pediatric Skin' below and section 'Skin Characteristics in Newborns and Their Susceptibility to IAD' in topic " Incontinence Associated Dermatitis - Introduction and Assessment"
• Unique developmental stages: Children's physical, emotional, mental, and intellectual development influences their responses to injury and treatment.
• Communication nuances: Communication strategies must be adapted to the child's age and cognitive awareness. 
• See section 'Communication Strategies in Pediatric Wound Care' below
• Collaboration with parents/caregivers: Care of pediatric patients requires collaboration with parents and caregivers, as they possess unique insights into their child's needs and cues. Involving them in decision-making and providing clear information leads to informed choices and improved patient outcomes.
• Specialized equipment and dressings: Pediatric patients require appropriately sized equipment and wound dressings.[1]
• Presence of rare or life-limiting conditions: Pediatric populations may present with rare diseases or life-limiting conditions not typically observed in adults, often with a poorer prognosis.
• Financial burden: from 2017 to 2020, the estimated national hospital charges for chronic wound-related admissions in pediatric patients (18 years or younger) was estimated at approximately US$1.15 billion. Notably, discharge to home healthcare was associated with a daily cost of US$11,818, which was significantly higher (p < 0.001) than other discharge dispositions, such as routine discharge or transfer to other facilities or short-term hospitals. [10]

Etiology of Pediatric Wounds

Infants and children may present with acute or chronic wounds, including:

• Acute wounds in children typically result from trauma - such as road traffic accidents, dog bites, lacerations, burns, scalds - or from surgical procedures. Wounds can also result from abuse or neglect.[1]
• Chronic wounds may be related to [1]:
• Pressure ulcers/injuries
• Invasive lines extravasation injuries or emboli-related ischemia
• Purpura fulminans from meningococcal sepsis
• Epidermolysis bullosa
• Myelomeningocele
• Ulcerated hemangiomas
• Vascular anomalies
• Autoimmune skin conditions
• Graft-versus-host disease 

Sections 'Assessment' and 'Common Pediatric Skin Injuries' below provides details on assessment and management of common pediatric wounds. 

Epidemiology

Prevalence of chronic wounds among pediatric patients

• A study analyzing the United States National Inpatient Sample (NIS) data from 2017 to 2020 identified 3,468 hospitalizations for chronic wounds in pediatric patients (18 years or younger).[10] Key findings from this study include:
• Age, gender: Over 72% of the patients were aged 6 years or older, with males accounting for more than 60% of the cohort.
• Payer: Medicaid served as the primary payer for 49% of these admissions.
• Primary diagnosis: More than 90% of hospitalizations had a primary diagnosis of osteomyelitis, and over half of the wounds were located in the lower extremity.
• Comorbidities: common comorbidities included cerebral palsy (8%), myelomeningocele (5%), and malnutrition (3%).

Developmental Considerations of Neonatal and Pediatric Skin

When evaluating wounds in neonatal and pediatric patients, it is critical to account for unique developmental factors that can support or impair wound healing.

Risk Factors for Wound Development in Neonates

• Premature and neonatal skin: 
• Fragile, underdeveloped skin: Premature and neonatal infants have all the cell layers in the epidermis and dermis, however the dermo-epidermal junction is much more fragile, making their skin highly vulnerable to trauma and infection.[1][4]
• Immature skin barrier: Premature skin is an inadequate barrier, better suited for the intrauterine environment, and poses a high risk for systemic absorption. This poor barrier function improves throughout the first year of life. [11][12][13][14][15][16]
• Transepidermal water loss (TEWL) and fluid balance:
• Heat loss: water loss through skin evaporation leads to heat loss. Infants (especially those <30 weeks gestation) experience increased TEWL, leading to heat and fluid loss.[15][16]
• Fluid balance in trauma and burn injuries: Large-surface-area injuries may require fluid resuscitation. Children maintain stroke volume primarily through tachycardia; they cannot increase contractility as efficiently as adults. Early correction of hypovolemia is essential to maintain perfusion and prevent progression to bradycardia and cardiac arrest.[4]
• Thermoregulation and hypothermia [4]:
• Preterm and neonatal infants are highly vulnerable to hypothermia because of:
• Large surface-area–to–body-mass ratio
• Limited keratinized skin
• Reduced brown fat for non-shivering thermogenesis
• Pediatric trauma patients with large open wounds are similarly at risk and require warm environments during assessment and procedures.
• Skin pH, microbiome and risk of infection [1]: 
• Skin pH: Newborn skin pH is approximately 6.0 during the first week, drops to 5.5 within the first six weeks, and stabilizes at 5.5 into adulthood.[1] A more alkaline surface weakens the skin’s antimicrobial barrier, making neonatal skin more prone to infection.
• Open wounds or denuded skin in neonates and children significantly raises the risk for local and systemic infection

Protective Factors in Neonatal Skin

• Enhanced epidermal turnover: Neonates have a thinner basal layer but higher keratinocyte turnover, which may contribute to more rapid re-epithelialization compared with adults.
• Vernix caseosa: This natural coating on neonate skin provides waterproofing, prevents TEWL, moisturizes, maintains neutral pH, and aids in skin development. Due to its protective function, it should be allowed to wear off naturally, avoiding aggressive removal.

Table 1 below illustrates key differences in neonatal skin. For further information on developmental considerations for neonatal and pediatric skin, please see section 'Skin Characteristics in Newborns and Their Susceptibility to IAD' in topic " Incontinence Associated Dermatitis - Introduction and Assessment".

Table 1. Key Differences in Neonatal Skin.[1][17]

Communication Strategies in Pediatric Wound Care

Effective, tailored communication is essential when caring for pediatric populations. The items below should be considered. [4]

Developmental Considerations

Growth and development follow a unique pattern for each child. A child's developmental age may not align with their chronological age, particularly if there is a history of cognitive or physical delays. In such cases, management should be guided by their developmental age. [4]

• Distraction strategies by age group include [4]:
• Infants: Parental engagement and comforting, pacifiers, music, swaddling, touch/massage.
• Toddlers: Similar to infants, with the addition of stories, peek-a-boo, toys, and bubbles.
• Preschoolers: Pinwheels, books, noise makers, comfort items, music, and stories.
• School-Age/Middle School/Adolescents: Electronic toys or computer games, television, guided imagery, deep breathing/relaxation techniques, and participation in procedures.

Practical Tips For Effective Communication With Pediatric Patients

Clinicians might opt to consider the communication strategies listed in Table 2 to enhance communication with pediatric patients. 

Table 2. Strategies for Effective Communication with Pediatric Patients  [4][18]

ASSESSMENT

History

The non-exhaustive checklist below highlights relevant factors that should be assessed when taking history of a pediatric patient with a chronic wound. 

Patient Demographics

• Age, gender, ethnicity
• Developmental stage: Consider milestones and mobility level (e.g., non-ambulatory infant versus active adolescent), as this could be related to both etiology and care planning.

Chief Complaint and History of Present Illness

• Ulcer characteristics: Onset (sudden vs. gradual), size changes, presence of multiple or recurrent wounds. Some pediatric ulcers (e.g., sickle cell leg ulcers) are prone to recurrence .
• Ulcer Location: Wounds over bony prominences may point to PU/PI. In ambulatory children, foot ulcers may suggest neuropathy or trauma.
• Current devices/dressings: Note use of orthotics, offloading devices, wheelchairs, or assistive equipment. Assess whether devices fit correctly for a growing child.
• Activity level: Note participation in sports or activities. Repetitive friction, pressure from orthotics, or prolonged immobility (e.g., wheelchair use) can contribute to the development of acute or chronic wounds. Assess impact of the wound on the child’s functional needs and ability to participate in school and play.
• Pain: Record onset, severity, location, and whether it limits daily activities or sleep. For younger children, use age-appropriate pain scales.
• History of conditions that predispose to chronic wounds: Examples include congenital or acquired neuropathies, structural musculoskeletal disorders, diabetes, sickle cell disease, epidermolysis bullosa, spina bifida, pressure, inflammation, and infection.
• Past treatments/surgeries: Vascular interventions, or surgeries that may have altered perfusion to the wound bed.
• Previous tests: Include labs, imaging, biopsies, cultures, or prior consultations (orthopedic, vascular, dermatology, etc). 

Medications

• Record all medications, including topical agents and over-the-counter remedies given by caregivers.
• Note drugs that may delay healing (e.g., steroids, chemotherapy agents, some antibiotics) .

Allergies

• Include medication, latex, and adhesive allergies.
• Ask about iodine sensitivity if imaging with contrast may be required.

Family History

• Note chronic wound history or predisposing conditions in siblings or parents (e.g., sickle cell disease, vascular disorders) .

Social History

• Caregiver support: Identify who performs daily wound care and assess caregiver capacity/training.
• Home environment: Evaluate accessibility, cleanliness, and safety (e.g., fall risks, adaptive devices).
• If applicable, evaluate proper fit of mobility aids
• Risk of friction/shear (wheelchair cushions, bed surfaces)
• Tobacco exposure: Second-hand smoke can impair wound healing and perfusion .
• Cultural/behavioral factors: Include beliefs that may influence wound care compliance.

Safeguarding / Non-Accidental Injury (NAI) Screening 

Concerns about maltreatment or abuse resulting in acute or chronic wounds must be accurately documented and immediately reported following local safeguarding protocols and state child protection laws. Raise suspicion if [1][19]:

• The reported mechanism of injury changes, differs, or is implausible/inconsistent with the wound.
• The mechanism of injury is not compatible with the child’s age, developmental stage, normal activities, or existing medical conditions.
• There is an unexplained delay in seeking medical attention.
• Parents or caregivers show a lack of appropriate concern.
• The child’s demeanor or behavior raises concern.

Review of Systems

• General
• Malnutrition or obesity: affects wound healing and mobility
• Fever, malaise: may indicate infection.
• Anemia, cachexia: risk factors for PU/PI
• History of cancer or immunosuppression: may impair wound healing
• Cardiovascular
• Congenital heart disease or vascular malformations may affect perfusion to the wound bed.
• Hypotension: may increase risk of PU/PI or delay healing.
• Endocrine
• Pediatric diabetes: risk for foot ulcers and neuropathy .
• Dyslipidemia or metabolic disorders affecting circulation.
• Neurological
• Spinal cord injuries, spina bifida, cerebral palsy: high risk for PU/PI
• Cognitive impairment may limit communication about pain or discomfort.
• Musculoskeletal
• Developmental hip disorders, fractures, or contractures can contribute to immobility-related ulcers.
• Peripheral vascular/lymphatic system
• Congenital lymphedema: risk factor for delayed wound healing and recurrent ulceration due to chronic swelling and impaired lymphatic drainage
• Skin
• Eczema
• Genetic disorders (e.g., epidermolysis bullosa, psoriasis) may complicate healing 

Structured Risk Assessments Related to Chronic Wounds in the Pediatric Patient

Effective wound management in pediatric patients requires a structured approach to risk assessment. Table 3 lists some of the validated tools for identification of risk factors contributing to chronic wounds in the pediatric population. [20] 

Table 3. Selected Validated Tools for Identifying Risk Factors for Chronic Wounds in Pediatric Patients

Nutritional Screening and Assessment

Disease-related malnutrition (i.e. malnutrition resulting from the underlying illness) is the most common form in industrialized countries and is associated with significant morbidity.[26] For details on nutritional screening and assessment in wound care, refer to topic "How to Screen, Assess and Manage Nutrition in Patients with Wounds".

Nutritional Screening in Pediatric Patients

• For all pediatric patients on admission to a healthcare setting, clinical practice guidelines and the U.S. Centers for Medicare and Medicaid Services (CMS) recommend that a pediatrician, registered dietitian/nutritionist or other qualified health professional conduct age-appropriate nutrition screening and assessment to identify patients at risk of malnutrition.[27][28][29][30][31] 
• Re-screen nutrition status with each significant change in the individual’s clinical condition.[27] 
• Child-appropriate nutritional screening tools should be used whenever available. [26]
• Among the commonly used nutrition screening tools below, the Pediatric Yorkhill Malnutrition Score (PYMS) appears to be the most effective for identifying children at nutritional risk. Clinicians may therefore consider prioritizing PYMS for routine nutritional screening. [26]
• Pediatric Yorkhill Malnutrition Score (PYMS) 
• Screening Tool for Risk on Nutritional Status and Growth (STRONGkids),
• Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP)

Nutritional Assessment in Pediatric Patients

• If a child screens positive for malnutrition risk, the healthcare team should request a consultation with a registered dietitian/nutritionist, who will conduct a full nutritional assessment, establish the nutritional diagnosis, and develop, implement, and monitor an individualized nutrition care plan.[27][31]
• For critically ill children and neonates, it is recommended that nutrition assessment be conducted on admission and at least weekly.[27] 
• Measure and document body weight, height/length and head circumference (in infants aged less than 3 years).
• Use z-scores for BMI for age to screen for children and neonates at the extreme.
• Use anthropometric measurements and growth charts to determine if the child is developing within expected growth patterns and adjust and correct measurements for gestational age for premature infants.
• Consider the influence of edema and fluid shifts in critically ill children

Patients' and Caregivers' Concerns

Pain and Anxiety

Effective pain management in pediatric patients is paramount, as pain is a subjective experience that must be recognized and addressed promptly by clinicians. Fear and anxiety can significantly intensify pain, increase disability, emotional distress, and the need for higher medication doses. [32] Therefore, pain and anxiety should be addressed holistically. All patients have the right to appropriate pain management treatment. [33]

Pain assessment

• Understanding the child's perspective: When assessing pain, explain the difference between "hurt" and "harm" at the child's level of understanding. [34]
• Locating the pain: Encourage the child to use one finger to point to the exact location of the pain. [1]
• Ongoing evaluation: Pain should be assessed continuously throughout wound management, ideally before, during, and after procedures such as dressing removal, cleansing, and dressing application. [35]
• Comprehensive assessment: Evaluate pain levels both at rest and during movement. Monitor the child's response to treatment to prevent undertreatment. [33] Commonly used pain assessment scales by age group are listed in Table 4.
• Acute versus. chronic pain:
• Acute pain: This is commonly associated with wound care and may stem directly from the wound or occur during procedures like cleansing and dressing changes.
• Chronic pain: In children, chronic pain often manifests as abdominal pain, limb pain, or headaches. [36] It is defined as persistent or recurrent pain (at least three times over a three-month period) and is typically not linked to minor injuries.[37]   However, chronic pain can also arise from hypertrophic/keloid scar tissue or contractures caused by tight scars. [1]
• Thorough assessment for systemic causes: Pediatric patients may report "pain all over." It is crucial to adequately assess pain to rule out systemic causes, but without increasing the child's anxiety. [1]

Table 4: Pain Assessment Scales by Age [1]

Ulcer Healability

Assessment of wound healability (i.e., the ability of the wound to achieve functional healing)  helps ensure responsible use of resources and supports the establishment of realistic treatment goals. Although many pediatric wounds are healable, confirming the healability of any chronic wound is essential. For further guidance, see the topic “How to Determine Healability of a Chronic Wound”.

Documentation

Accurate documentation is essential for safe, effective care, especially when developing a patient-centered plan for pediatric patients with wounds. Key aspects of effective documentation include [1]:

• Clear and accessible information: Provide written instructions on dressings and the treatment plan for the patient (when appropriate) and parents/caregivers. Use language that is easy to understand and supports active participation in care.
• Age-appropriate education: Tailor education to the child’s developmental level. Adolescents, in particular, benefit from one-to-one teaching that respects privacy and promotes autonomy.
• Benefits of patient education: Effective education can reduce symptom distress, improve engagement with the treatment plan, and increase patient knowledge. Children and adolescents may also benefit from peer support and shared experiences.[38]
• Documentation of clinical rationale: Record the reasoning behind any modifications to the management plan to ensure continuity and accountability.

MANAGEMENT

Care of pediatric patients should be holistic and patient centered, addressing the needs of the whole child, not only the wound, and considering the overall experience of the child and family.[1]

Best practices of pediatric wound management include [1]: 

• Treating children, adolescents, and their parents as partners in care, who help shape and plan the treatment approach.
• Coordinated services around the needs of the child and family, with clear information provided to support informed consent and engagement.
• Providing age-appropriate care; for example, children and adolescents should be encouraged to self-report pain.

Treatment Goals

The key goals of holistic wound management in children are to minimize pain, reduce emotional distress, and limit scarring.[1]

Treat the Cause and Co-factors Impeding Healing 

For all pediatric patients: 

• Address the underlying causes of the wound: Effective management begins with correct etiology identification and appropriate management of the condition causing the wound. 
• Acute wounds often result from trauma (e.g. burns, falls, etc), surgical procedures, acute medical conditions (e.g. purpura fulminans due to meningococcal sepsis), or abuse or neglect.[1] Management focuses on ensuring safety to prevent further injury, supporting surgical recovery, and providing appropriate medical treatment.
• Chronic wounds require identification of the underlying cause and coordination with an interprofessional team to address contributing factors.[1] Etiologies include:
• Pressure injuries caused by pressure, friction, or shear, often from medical devices (see section 'Pressure Ulcers/Injuries' below)
• Extravasation injuries or emboli-related ischemia from invasive lines
• Epidermolysis bullosa
• Myelomeningocele
• Ulcerated hemangiomas
• Vascular anomalies
• Autoimmune skin conditions
• Graft-versus-host disease
• Address co-factors that impede healing [1]:
• Identify and manage factors that may delay healing or contribute to new or recurring wounds, including:
• Medications
• Co-morbidities (e.g., diabetes, autoimmune disease)
• Nutritional status and hydration
• Support and resources available at home

Section 'Assessment' below provides details on assessment and management of common pediatric wounds.

Address Patients' and Caregivers' Concerns

Pain

Decisions about the type of analgesia must be made by a suitably qualified healthcare practitioner before prescribing and administering treatment.[1]

Anxiety can intensify both the perception and intensity of pain.[1] Thus, incorporating nonpharmacological methods of pain management can be beneficial. Listed below are nonpharmacological and pharmacological pain management strategies for the pediatric patient.

Nonpharmacologic Pain Management Strategies

Nonpharmacologic pain management strategies include [1][4]:

• Anxiety and pain management: Address anxiety alongside pain and ensure adequate pain relief in addition to routine analgesia.
• Behavior contracting: Utilize rewards or tokens.
• Comfort: Keep the patient warm.
• Containment: Employ swaddling, parent holding, and comfortable positioning.
• Distraction: Utilize video games, television, phones, tablets, pet therapy, or child life therapy.
• Guided imagery/storytelling: Engage the patient or healthcare provider in guided imagery or storytelling.
• Hypnosis: Consider hypnosis as a pain management strategy.
• Oral sucrose: Use for short-term infant pain management.
• Patient Control: Allow the child an age- and status-appropriate degree of control and participation.
• Positive self-talk: Discuss positive outcomes following procedures.
• Preparation: Allow appropriate time for preparation, prearranging care times with parents/carers when possible.
• Relaxation techniques: Encourage deep breathing and relaxation exercises.
• Thought stopping: Implement redirection and positive reinforcement.

Pharmacological Pain Management Strategies

The least invasive route that is most likely to provide effective pain control should be used. See Table 5. 

Pharmacological pain management options include [4]:

• Types:
• Non-steroidal anti-inflammatory drugs
• Opioids
• Co-analgesics:
• Antidepressants
• Anticonvulsants
• Anxiolytics
• Routes:
• Topical
• Intranasal
• Intradermal
• Oral
• Intravenous
• Patient/family/nurse-controlled analgesia
• Subcutaneous
• Intramuscular

Table 5: Commonly Used Analgesics for Pediatric Patients [1]

Local Wound Care

For all patients, appropriate local wound care should be implemented. This section summarizes local wound care interventions for pediatric patients. For customized, wound-specific recommendations, refer to the  "Wound Prep and Dress Tool".

Dressing Removal

• Epidermal blistering and stripping in pediatric patients with wounds often occur as a result of adhesive dressings or adhesive tape used to secure tubes and lines. These injuries are among the leading causes of skin breakdown in neonatal intensive care units.[1]
• Epidermal stripping can be reduced by maintaining good skin hygiene, applying a sterile silicone barrier film before placing dressings, and using silicone tapes or non-adhesive dressings whenever possible.[1]
• When adhesive products are required, they should be applied gently and removed using a sterile silicone adhesive remover.[1]

Cleansing

Wound cleansing is not required for every wound, but it can be an important component of care. Cleansing helps reduce microbial load, improves visualization of wound tissue, and prepares the wound bed for further management and dressing application. The decision to cleanse and the choice of cleansing solution should be based on a holistic assessment of both the patient and the wound.[1]

General principles for wound cleansing

• Individualized approach: Cleansing must be tailored to the patient’s clinical condition, developmental stage, and wound characteristics.
• Temperature: Use cleansing solutions warmed to body temperature for comfort and to support healing. [39]
• Risk of bleeding: Avoid cleansing wounds with a high bleeding risk (e.g., hemophilia, coagulopathies). In such cases [1]:
• Apply a wound gel directly to the dressing to aid gentle cleansing, or
• Use dressings with built-in cleansing properties.

Special Considerations for Neonates and Infants

• Preterm infants are vulnerable to cold stress during wound care and may sustain chemical burns from certain agents.[1]
• Disinfectants can cause skin injury, especially in premature infants and those under 2 months of age. [16][40]
• Maintain a warm environment and minimize exposure time during cleansing.

Recommended Cleansing Solutions

• Normal saline or sterile water: Safe for all ages.[11][16][41]
• Hypochlorous acid (HOCl): Increasingly used in neonates and pediatrics due to favorable pH compatibility and safety profile.[42][43]

Solutions Not Recommended for Wound Cleansing

• 70% isopropyl alcohol: Not appropriate for wound cleansing; cytotoxic.[16][40]
• 10% povidone-iodine: Not recommended for routine wound cleansing; rinse with saline if used for procedural prep. Risk of thyroid suppression in premature infants.[15][16][40]
• Chlorhexidine (CHG): Use with caution in low birth weight infants and those under 2 months. Suitable for procedural skin prep rather than wound cleansing. [11][16][40][41]

Bathing as a Cleansing Method

Bathing may facilitate dressing removal and wound cleansing while minimizing pain and trauma. Best practices include [1]: 

• Soap: Use mildly acidic soaps (pH 5.5–7.0) approved for newborns. [4]
• Water temperature: Warm water helps with cleansing and reduces discomfort. [4]
• Tap water: If using tap water, allow it to run for 5 minutes before filling the tub to reduce microbial load. [1]
• Privacy: Maintain privacy and dignity, especially for older children and adolescents.[44]

Debridement

• Debridement plays an important role in preparing the wound bed and promoting healing. It can support structural restoration, remove necrotic tissue, reduce bacterial load, and help resolve wounds that are stalled in the inflammatory phase.[1]
• For pediatric patients, autolytic debridement is a commonly used debridement modality, with or without a mechanical debrider (e.g., microfiber pad or “lolly”). Enzymatic debridement is also used when clinically appropriate.[45]
• For neonatal skin and extravasation injuries, it is crucial to assess the injury's depth and the potential for debridement to expose underlying structures. A "wait and see" approach might be necessary until the patient's clinical condition stabilizes and the wound is ready to heal. Regular observation will help determine the appropriate timing for debridement. [1]
• For further information on debridement, refer to topic "Debridement".

Infection and Bioburden Control

• Given the rise of microbial antibiotic resistance, antimicrobial stewardship is essential when considering treatment. This involves thoughtful consideration of wound debridement, appropriate wound cleansers, the necessity of antimicrobial dressings, and/or the need for antibiotic therapy. [1] 
• For additional information on infection and bioburden control, refer to topic "Antimicrobial Stewardship In Wound Care".

Peri-wound Care

Moisturizing [4]:

• If not contraindicated, consider moisturizers for all patients.
• Emollients, such as petrolatum (petroleum jelly) and non-petrolatum (safflower and sunflower oil) based moisturizers, are ideal for premature infants.
• Avoid known allergen-causing additives like lanolin or fragrance, which can cause irritation in neonatal and pediatric patients.

Moisture Management and Dressing Selection

Most wound dressings have been developed and tested primarily in adult populations, and high-quality pediatric evidence remains limited. As a result, clinicians often need to adapt available products for safe use in children, minimizing the risk of peri-wound skin damage by avoiding unnecessary coverage of intact skin. Dressing products selected must be proven safe and appropriate for the indication and the pediatric population.[1]

Special considerations for dressing selection for the pediatric population are listed below in Table 6. Wound products commonly used in pediatric patients are listed in Section 'Wound products commonly used in pediatric patients' below.

• Dressing selection in pediatric patients is guided by [1]:
• Wound-healing phase
• Wound location
• Exudate amount
• Tissue type present
• Age and developmental considerations
• Signs of colonization or local infection 
• All open wounds are colonized with microorganisms; however, non-multiplying organisms are not typically of clinical concern. 
• For wounds that become clinically infected, follow local protocols and seek input from a specialist member of the multidisciplinary team, in accordance with local guidelines. [46]
• All infection management should align with antimicrobial stewardship (AMS) principles.[46]
• In general, prophylactic antimicrobial use is strongly discouraged.[46]

Table 6: Special Considerations in Pediatric Dressing Selection [1]

Wound products commonly used in pediatric patients

Specific dressing types commonly used in pediatric patients are listed below.[1][4]For details, refer to topic "Dressing Essentials".  For customized, wound-specific recommendations, refer to the  "Wound Prep and Dress Tool".

• Acrylic/transparent tapes/dressings: While offering high adhesion, these carry a risk of epidermal stripping and should be used in conjunction with adhesive removers. [11][41]
• Adhesive removers: Silicone-based removers are preferred due to their rapid evaporation and lack of systemic absorption. [11][41]
• Alcohol-free barrier films/cyanoacrylates: These serve as a protective barrier against moisture and are beneficial for compromised skin. Alcohol-containing versions should be avoided. [11][16][40][41]
• Alginates/hydrofibers: Exercise caution when using these in neonates. They are effective for managing heavy exudate and allow for atraumatic removal. [11][12][41][48] 
• DACC-coated dressings: These hydrophobic dressings reduce bacterial colonization without systemic absorption risks and have demonstrated safety in neonates and pediatric patients. [49]
• Hydrocolloids: These dressings conform well and protect the skin; however, they may induce medical-adhesive skin related injuries (MARSI), with maceration or erythema. Their use should be avoided with moist medical devices.  [11][40][41][50]
• Hydrogels: Known for their soothing properties and atraumatic nature with electrodes, hydrogels are suitable for dry wounds and autolytic debridement.[11][12][41]
• Ionic silver-based dressings: Available in various formulations, these dressings are considered safe for use in neonates and pediatric patients. [16][40][51]
• Medical grade honey: Promotes wound healing through its acidic pH. Initial stinging sensations are possible. [52]
• Negative Pressure Wound Therapy (NPWT): NPWT is safe and effective in pediatric populations. For infants under one year of age, lower pressures (-50 to -75 mmHg) should be employed. Close monitoring and interdisciplinary team involvement are crucial. [11][41]
• Polymeric membrane dressings: These facilitate autolytic debridement and reduce pain during removal. They are available with or without silver. [12]
• Silicone/silicone foams: These dressings minimize discomfort during removal and are better suited for protection rather than strong adhesion to plastic surfaces. 
• Zinc-based adhesives: Avoid these in neonates as they may impair barrier function and increase TEWL. [53]

Plan Reassessment

Regular reassessment is essential for monitoring healing progress and guiding ongoing management.[1] 

Best practices include [1]:

• Record baseline data as part of the initial holistic assessment and continue to monitor and document findings throughout treatment.
• Reassess the patient and wound at regular intervals, and document progress, delayed healing, or signs of infection.
• Documentation should include:
• Wound and tissue characteristics
• Indicators of healing or deterioration
• Factors impeding healing
• Whether treatment modifications are needed
• Review and revise the plan of care based on the most recent assessment of both the patient and the wound.
• For suspected or confirmed infection or when the wound fails to heal despite adequate treatment, consult a specialist member of the multidisciplinary team.
• Document the clinical rationale for any changes in management.

COMMON PEDIATRIC SKIN INJURIES

Pressure Ulcers/Injuries

It is important to remember that pediatric patients are not “mini adults,” and their care requires a developmentally tailored approach.[1] Key differences include [1]:

• Developmental variation: Physical, emotional, and cognitive stages differ widely across ages.
• Unique conditions: Children may present with rare or life-limiting disorders not seen in adults.
• Communication differences: Abilities to express needs vary by age and developmental level.
• Family partnership: Parents and caregivers know the child’s cues and play an essential role in shared decision-making.

This section outlines key challenges in pediatric PU/PI assessment, management and prevention. For assessment of PUs/PIs, refer to topic "Pressure Ulcers/Injuries - Introduction and Assessment". For common classification systems with pictures and descriptions, see "Pressure Ulcers/Injuries - Classification/Staging". For management of pressure ulcers/injuries see "Pressure Ulcers/Injuries - Treatment". For prevention strategies, see "Pressure Ulcers/Injuries - Prevention". For best practices in care coordination, see "Pressure Ulcers/Injuries -Coordination of Care".

Background

• Definition: Pressure injuries/ulcers (PUs/PIs) are localized damage to the skin and/or underlying tissue, usually over a bony prominences or related to a medical or other devices, resulting from prolonged pressure or pressure in combination with shear. The lesion can present below intact skin or as an open ulcer, which may be painful. Synonyms for this condition include, bedsores, decubitus ulcers, pressure sores and many more.[54]
• Common PU/PI locations: Pediatric patients are particularly vulnerable to tissue damage in areas such as the occiput, ear, nose, sacrum, and heels, as well as at sites where medical devices are applied. [55][56] 

Epidemiology

• Incidence:
• Overall PU/PI incidence in pediatric patients is 13.5%.[56] 
• Prevalence:
• Global PU/PI prevalence in pediatric patients ranges from 1.72% to 18.6%.[1]
• Prevalence is higher in pediatric intensive care units (PICU/NICU) compared with general pediatric wards.[1]
• Device–Related Pressure Injuries (DRPI):
• DRPI are common in neonatal intensive care units, particularly among extremely preterm infants.[1][57]
• In pediatric populations, DRPI account for 38.5% to 90% of all pressure injuries.[4]
• Global incidence of DRPI in pediatric acute care settings is 11.0%. [56]
• Global prevalence of DRPI  in pediatric acute care settings is 12.6%. [56]

Risk Factors

Children who are critically ill, or those with chronic or terminal illnesses, face the highest risk of developing pressure injuries. [4]

Risk factors for development of PU/PI among pediatric patients include [1]:

• Neonates and preterm infants [1]:
• Skin fragility: Inability to frequently reposition neonates due to fragile skin and the caloric expenditure involved.
• Humidified environments: Extreme preterm babies managed in humidified environments to prevent transepidermal water loss.
• Dry skin: Preterm babies with very dry skin (due to reduced sebum and sweat production) are susceptible to damage from excessive handling.
• Medical devices and equipment [1]:
• Asymmetrical pressure: Use of medical devices when the face/head is not symmetrical can cause unilateral pressure, necessitating padding.
• Limited equipment sizes: A restricted selection of appropriate equipment sizes.
• Mobility and compliance [1]:
• Sacral and heel pressure: Older pediatric patients are at risk of pressure damage to the sacrum and heels, requiring encouragement and motivation for repositioning.
• Concordance issues: Patients may remove pressure-relieving devices or engage in physical activity causing friction. Reduced cognitive awareness (due to age or medical condition) can also contribute.
• Prolonged wheelchair use: Children with complex needs spending extended periods in wheelchairs are prone to sacral/buttock pressure damage, especially if incontinence is present.
• Communication and Sensation [1]:
• Non-verbal communication: Children with complex needs may be non-verbal and unable to communicate pain.
• Impaired sensation/circulation: Spinal injuries or conditions can lead to impaired or absent sensation and circulation, increasing risk.

Structured Risk Assessment

• 1CClinical guidelines recommend performing a PU/PI risk assessment upon the patient's admission to a healthcare setting, and on a regularly scheduled basis (Grade 1C). [58]
• Refer to section 'Structured Risk Assessments Related to Chronic Wounds in the Pediatric Patient' above for Assessments for PU/PI in pediatric patients.

Management and Prevention

Challenges in managing and preventing PU/PI in pediatric patients include the need to accommodate their ongoing growth, developmental differences, and unique loading requirements.

• Equipment-related challenges: Splints, wheelchairs, seating systems, and positioning devices require frequent reassessment as the child grows. Many traditional support surfaces were developed for adults, and their effectiveness for children with lower body weight or smaller body size remains uncertain.[1]
• Need for pediatric-specific surfaces: Because children are not “mini adults,” they require pressure-redistribution products designed for their distinct body proportions and loading patterns. Innovations in surface design now include neonate-specific products and pediatric mattresses without minimum weight limits.[1]

For detailed management guidance, refer to "Pressure Ulcers/Injuries - Treatment". For prevention strategies, see "Pressure Ulcers/Injuries - Prevention". 

strategies for Prevention and Management of Medical Device-Related Pressure Injuries

Collaboration among all members of the multidisciplinary team (e.g., occupational therapists, physiotherapists, specialist nursing teams) is essential for optimal outcomes.[1] Table 7 below lists best practices and recommendations by international clinical practice guidelines.[57] 

Table 7. Best Practices and Recommendations on Device-Related Pressure Injuries by the National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA). [57]

Moisture-Associated Skin Damage

Moisture-Associated Skin Damage (MASD) is classified as an irritant-contact dermatitis. [59]  Common irritants, such as urine, stool, perspiration, saliva, intestinal fluids from stomas, and wound exudate, contribute to skin breakdown. An elevated alkaline pH further increases this risk, creating an environment susceptible to microbial invasion, which can lead to infection or Candida albicans. [4]

The broader term MASD encompasses four main categories:

• Incontinence-associated dermatitis (IAD): 
• IAD is one of the most common skin complaints in infants, but can occur in patients of any age [1] 
• Refer to topics  "Incontinence Associated Dermatitis - Introduction and Assessment" and "Incontinence Associated Dermatitis - Prevention and Management in Newborns and Infants".
• Intertriginous dermatitis (intertrigo): see Table 8 below
• Peristomal dermatitis: see Table 8 below
• Periwound maceration: see Table 8 below

Other Common Pediatric Wounds

Table 8. Other Common Pediatric Wounds