A pressure injury (also known as pressure sore, pressure ulcer or bed sore) is an area of the skin that has been damaged as a result of constant pressure, poor blood flow or chafing and rubbing of the skin.
People of all ages, including babies and children, are at risk of developing pressure injuries. Children who are at increased risk of developing a pressure injury include those with spina bifida, a spinal cord injury, neurological impairment or other medical condition that restricts their
ability to move, or children who have an orthosis or prosthesis.
Many pressure injuries are preventable with careful management of your child, both in hospital and at home following discharge. A pressure injury is much easier to prevent than treat.
Signs and symptoms of pressure injuries
Common signs of a pressure injury include:
- red marks
- blue or purple areas (in darker skin)
- broken skin
Pressure injuries can appear anywhere on the body, however, common areas on children are:
- back of the head (especially in babies, infants and toddlers) and ears
- tailbone (sacrum/coccyx), hips and buttocks
- heels and elbows
- spine and shoulder blades
- under plasters, casts, splints or braces
- around medical equipment (e.g. tubes, masks, drains etc).
What causes pressure injuries?
A number of factors may lead to your child developing a pressure injury, including:
- reduced activity – sitting or lying in the one place for too long
- sitting in wet clothing, a wet bed or a wet nappy for long periods
- pressure or friction to one area of the body
- lying on crumpled sheets or wearing clothing with thick seams
- reduced feeling in the skin.
Children with poor nutritional or fluid intake, a weakened immune system or those who are extremely unwell are at increased risk of developing pressure injuries.
Prevention in hospital
While in hospital, nursing staff will assess and monitor your child for pressure injuries on a daily basis. If your child is at risk of developing a pressure injury, staff will discuss a management plan with you. This plan may include the following strategies:
- positioning in bed
- applying a dressing to bony or reddened areas
- using special slide sheets to move your child in bed
- using barrier creams
- using absorbent bedsheets
- frequent inspection of at-risk areas of skin
- increasing nutritional and fluid intake (this may be via a tube if your child is unable to eat or drink)
- helping your child to change their position every two to four hours during the day and night (it is always best if your child can do this themselves, but staff will assist if needed)
- repositioning medical equipment
- using pressure-relieving products (e.g. gel pads, air mattresses).
Nursing staff may refer your child to other members of the healthcare team to contribute to their management plan, such as an occupational therapist, a physiotherapist or a dietitian. If your child has an existing pressure injury that requires dressings, a nurse specialising in wound
dressings (nurse practitioner or stomal therapist) may also be asked to assess your child.
Care at home
Pressure injuries can be serious and may take months to heal. They can be painful and add to a child's existing health problems. Careful attention to the condition of your child's skin, prompt attention at any sign of damage, and maintaining a healthy diet is important for your
child. The more active your child is, the lower their risk of a pressure injury.
- Check your child's skin regularly, in the morning and at night.
- Look for blisters, bruising, cracks, scrapes, changes in skin colour (redness or darkening), or dry skin.
- Closely inspect high-risk areas such as bony areas (heels, ears, buttocks, hips, elbows etc) and skin under and around casts, splints, braces or medical equipment.
- Watch for areas that are constantly moist, such as the groin and buttocks, especially if your child is incontinent or not toilet trained.
- As you cannot look under plaster, monitor your child if they have any increased pain or discomfort under the cast.
- Encourage your child to change their position at least every two hours if sitting for long periods.
- If your child is spending extended periods of time in bed, encourage them to change their position regularly – every two hours during the day and four-hourly overnight. If they require your assistance to change position in bed, be careful not to drag their skin when moving. Your
child can be positioned on their left side, back and right side while in bed. Make sure bed sheets are tightly tucked in and not crumpled. Small creases or folds in sheets can damage the skin.
- Encourage your child to be active where appropriate.
- Use lukewarm water for bathing and showering.
- If using soap or liquid cleanser, try to use a product that is pH neutral, unperfumed and alcohol free.
- Apply a plain, non-perfumed moisturiser top-to-toe after bathing daily.
- A barrier cream (available at any pharmacy) on inflamed or bony areas may be helpful for your child.
- Good nutrition is important for healthy skin and wound healing.
- A balanced diet helps your child maintain an appropriate weight.
- Encourage your child to drink adequate fluids throughout the day. Caffeinated drinks such as cola should be avoided.
If your child requires long periods of bed rest and has reduced activity, an occupational therapist may recommend the use of specific equipment for your child at home to reduce the risk of pressure injuries.
These may include:
- a medical sheepskin (pure wool sheepskins that have been sterilised)
- gel pads
- a specialised foam mattress or air mattress.
The occupational therapist will advise you where these products can be hired or purchased. If you have not seen an occupational therapist and would like to, your GP or nursing staff can organise a referral for you.
What to avoid
- Avoid stretching or pulling the skin (e.g. do not drag your child when moving them in bed or transferring in and out of bed).
- Avoid massaging or rubbing areas of broken skin, as this may cause further damage.
- Do not use 'donut' or 'ring' cushions – these increase your child's chances of developing a pressure injury.
- Don't dress your child in clothes with thick seams (e.g. thick track suit pants) as the seams can cause pressure injuries.
When to see a doctor
If you notice a pressure injury on your child at home, identify the cause and remove it where possible. Reposition your child so they are not directly on the pressure injury.
If the pressure injury does not heal within 24 hours or the skin is broken, contact your GP or treating healthcare provider.
Pressure injuries can be a sign of a deeper wound and need to be assessed as soon as possible.
Treatment for pressure injuries
Prevention is the key. But when pressure injuries do occur, they will be treated like a wound, with regular dressing changes and checks by nurses or doctors. When the area is showing signs of infection (red, warm, painful, swollen), antibiotics may be required to help treat the infection.
Key points to remember
- A pressure injury is much easier to prevent than treat.
- Signs of a pressure injury are red or blue/purple marks on the skin, blistering, broken skin and pain.
- At home, carefully monitor your child's skin, and act quickly if you see signs of damage.
- Seek medical advice if the skin is broken or the injury does not heal in 24 hours.
For more information
Common questions our doctors are asked
Should I set an alarm to wake in the night to go and change
my child's position?
This is usually not necessary, especially if your child
sleeps on a soft surface, like most mattresses. If your child is at increased
risk of pressure injuries, your child's doctor will advise whether regular
repositioning is required.
How long will it take for my child's pressure injury to
Most pressure injuries begin healing within 24
hours. Wound healing can be delayed for the following reasons: in children with
poor blood flow (perfusion); if your child is taking medication that weakens the
immune system; if the wound becomes infected; and by other medical conditions.
Have your child seen by a doctor if their pressure injury is not improving
within 24 hours.
Developed by The Royal Children's Hospital Nursing Services department. We acknowledge the input of RCH consumers and carers.
Reviewed July 2018.
This information is awaiting routine review. Please always seek the most recent advice from a registered and practising clinician.
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