A scoping review to inform a multi-disciplinary approach for nutrition therapy in critically ill children with pressure injuries

Abstract

Nutrition status plays a critical role in pressure injury (PI) healing and yet the available literature, especially in pediatric patients, is limited. Critically ill pediatric patients are at an increased risk of skin integrity compromise and PI development. Adequate nutritional intake can often be challenging to achieve in this population and immobility and illness present additional obstacles to maintaining skin integrity in this vulnerable population. Despite the unique nutritional challenges and needs of this group, there is no standardized approach to macro-and micronutrient management and monitoring. Here, several key vitamins and minerals believed to play a role in PI healing are discussed and an approach to nutritional management and monitoring for PI healing in pediatric patients is proposed. Registered dietitians (RD) are essential to assess individual patient macro and micronutrient requirements, to identify gaps and make recommendations to optimize nutritional therapy that may exist and impact wound healing. We used a scoping review to focus on the interplay of nutrition and PI healing and inform a multidisciplinary approach to PI identification and management. Through this review, we propose a strategy for the nutritional management of pediatric patients <30 kg at risk for and who present with PI.

Nutrition association with skin integrity and pressure injury in critically ill pediatric patients

“…A multidisciplinary approach that incorporates frequent physical assessments, identification of risk factors, skin care routines, and optimal nutrition delivery inclusive of fluids, macronutrients, and micronutrients is necessary. The skin assessment should include use of a validated PI risk measurement tool such as the Braden QD (Table 2), validated and recommended for pediatric use, 20 and include areas under and adjacent to medical devices, as well as any areas where a medical device traverses the skin, skin folds, dependent areas, and those areas of skin that may be susceptible to shear 20,23,33 …”

“…Vitamin A deficiency can lead to deterioration of skin integrity and poor wound healing 53 . Vitamin C is associated with collagen synthesis and has a protective role against skin damage; therefore, a deficiency can negatively impact skin integrity, increasing the risk for skin breakdown and poor wound healing 23,54,56 . In an adult study of surgical ICU patients, vitamin D level at ICU presentation was inversely associated with PI development 57 .…”

“…There are no established intervals for obtaining follow‐up laboratory monitoring of micronutrient levels. Table 4 provides suggestions for macronutrient and micronutrient management based on PI staging 23 . The monitoring and interpretation of laboratory values together with the child's course of illness and clinical status, macronutrient intake, and any micronutrient supplementation prescribed must be evaluated concomitantly to determine ongoing requirements and a schedule for follow‐up laboratory monitoring.…”

“…21,22 Medical devices necessary during illness such as noninvasive positive-pressure ventilation appliances, endotracheal tubes and securing apparatuses, tracheostomy tubes and ties, pulse oximetry probes, and other medically necessary tools with skin failure (as described) increase the risk for breakdown of skin integrity and occurrence of PIs. 23 The incidence of skin injury in critically ill children is reported to be between 10% and 27%, with prevalence described up to 43%. 15,16,18,[24][25][26][27][28] These data and clinical practice anecdotes suggest as many as 1.4% of hospitalized pediatric patients experience a PI.…”

“…20,33 It is the responsibility of the entire multidisciplinary care team to participate in the prevention, recognition, and treatment of alteration(s) in skin integrity. 23…”