Skin and Risks in Pediatrics: Analysis of a Hard Problem

• Published in: Ostomy/wound management Vol. 58; no. 1; p. 1
• Main Author: naciari, M
• Format: Journal Article
• Language: English
• Published: King of Prussia HMP Communications 01.01.2012
• Subjects: Pediatrics; Pressure ulcers; Risk assessment; Skin diseases; Wound healing
• ISSN: 2640-5237; 2640-5245

The use of a rating scale of the risk of skin lesions is certainly a strategic element. The rating scales of risk of pressure sores in adults have been 50 years, and in the pediatric population, around 11 at the time, have a little less than 20 years. What have we learned in the meantime? We have learned that: 1. Need more rating scales because the pediatric ages are different between them and we do not have a scale suitable for all these ages. 2. Of 11 scales, we have at least 2 scales for the pediatric age sufficiently reliable, though not suitable for all ages and all the pediatric setting: Braden Q and Glamorgan. 3. Unlike other assessment and rating systems, you must retest and revalidate according to several parameters: time, contextualizing the scale that we have chosen before introducing it in use, time consumed, and resource. 4. There is no agreement about the use of sensitivity and specificity as indicators of the performance standards of the rating scales. 5. There is no agreement and consensus about the clinical efficacy. 6. The predictive value of these tools has rarely been assessed either separately for each item or total. 7. Perhaps we have too much meaning attributed to the assessment tools, entrusting to them the identification of patients at risk. 8. It is highly likely that the scales do not take account of racial differences and the different colors of skin. 9. Scales assess the risk of pressure sores, while we know that, in view of the differences from adults, children do not talk so much and not always of pressure sores but skin breakdown (failure of the skin), a term that includes, in addition to pressure sores, all the insults to the skin integrity they see as the main causes of friction, moisture, temperature, and all the devices in contact with the skin of the child. The prevalence of skin breakdown, purified from pressure sores, is higher than the same pressure sores, and consists primarily of excoriation/diaper dermatitis, skin tears, and IV extravasation sites. 10. There is no rationale to use PU risk scales as a quality indicator for care processes. 11. As of today, there is no evidence that prevention is more effective if PU risk scales were used. 12. The use of rating scales of risk alone does not improve clinical practice. 13. Too often in Italy, these scales are used as the sole parameter for the choice of type of surface: in the Italian health system we have an extreme need for priority allocation of resources. 14. Risk assessment tools should only be used as an aide memoire and should not replace clinical judgment. One limitation in addition, in pediatric ages as listed above, is the fact that they assess the risk of pressure sores, while we know that the risk in those aged skin is multivariate and multifactorial, where the pressure is one of many causes: this should lead us to include, among the risk factors for skin, always new elements such as edema and accepting the challenge of measuring them. Can all of these be considered good reasons for not using risk assessment scales in the pediatric age? Certainly not. But they should be considered good reasons to induce us all to some reflection. It is my opinion that, in addition to disseminating and implementing the use of risk assessment scales and giving them a dominant role as an instrument of research and comparison, we should focus our efforts in developing a comprehensive approach to skin hazard in the pediatric age, putting it in a broader logic, mainly organizational, management of risk (such as "Quality Risk Approach") so as to cover the focus on Quality, and Patient and Health Workers Safety, as intended as a psychophysical, as both in medical and legal responsibilities. We should therefore act on the process and health workers, that is on ourselves and our environment, in a combination of training, continuity of care, and organization. Therefore, in this view, relevant aspects such as skin care programs, documentation, emotional and educational spheres of health professionals, the selection of medical devices and aids, the involvement of parental figures, the economic policies of the health system -- both the micro and the macro -- and the exploration of the socio-economic and cultural environments and needs of our youngest patients should be addressed.