Single-use Negative Pressure Therapy and the Pediatric Patient

To return to the pre-COVID theme (interesting congenital neonatal conditions and their management), this month’s column focuses on a treatment approach commonly used in various neonatal and pediatric cases: the application of negative pressure wound therapy (NPWT). 

What we consider modern NPWT was first provided in 1980 by Russian army surgeons; it made its way to the United States by 1989, initially as a method to drain enterocutaneous fistulas. Its use became more accepted in adult medicine in 1990 to facilitate epithelialization and wound closure. Currently, NPWT is used to manage acute and chronic wounds, prevent surgical site infection, and facilitate grafts and incision integrity. NPWT devices have evolved from bulky and cumbersome to small and portable and from traditional canister models to single-use, battery-operated, portable models. NPWT foam dressings have evolved from black, hydrophobic, open-cell polyurethane to white hydrophilic to perforated, less-adhering varieties. Drapes have gone through a similar evolution, leading to strong adhesion with less traumatic removal. Closed incision NPWT is now considered a supportive, preventative modality, and NPWT with installation has added an extra infusion of infection prevention.² 

In step with industry, practitioners have made great strides in maximizing opportunities for NPWT utilization. We have evolved from complete fear of pediatric/neonatal NPWT to efficient, safe, and efficacious inpatient and outpatient use of NPWT. This month, I am delighted to share the proverbial lectern with Ferne Elsass, MSN, RN, CPN, CWON, a board-certified wound ostomy and pediatric nurse specializing in pediatric and neonatal wound care at Children’s Hospital of The King’s Daughters, Norfolk, Virginia, for the past 20 years. Drawing on her experience, she describes the use of single-use NPWT to facilitate at-home management of challenging wounds.

Elsass: NPWT is a mainstay treatment for wound care; it improves the granulation within a wound and manages fluid while still maintaining a moist wound environment.^1,3 Although still not a popular go-to modality for some pediatric clinicians, NPWT can be and is used with the same frequency and with similar steps and precautions as in adult counterparts.^2-4 As with adult patients, a sponge and prescribed negative pressure are applied to the wound bed; use in pediatric patients requires adjustments based on age and weight, along with careful observation.^3-5 NPWT has been shown to be safe and effective in neonatal and pediatric patients, providing wound and exudate management and advanced wound healing.⁷ 

Although a safe option for the pediatric population, traditional NPWT requires large and cumbersome equipment. The pediatric population and its care providers may find the equipment intimidating and that it further limits patient activity. In addition, neonatal and pediatric patients require closer monitoring related to many of the same concerns that apply to adult patients, such as bleeding and discomfort.³ As such, young patients require an increased amount of restraint related to the equipment, placing additional confines on activity. Dressing changes are suggested several times a week; pediatric patients and their families may feel anxious about dressing changes that often require pain medication and sedation.^3-5,7 Dressing removal, if painful, makes future dressing changes overwhelming for patients and their families.² Because the United States Food and Drug Administration does not recognize NPWT for neonatal or pediatric patients, insurance coverage for outpatient NPWT may be restricted or denied for patients under the age of 12 years, requiring patients to remain in the hospital until the completion of treatment¹ or to seek other, nonevidence-based means of wound care.  

Single-use/disposable NPWT is an alternative to traditional  NPWT. The single-use version consists of a silicone border dressing connected by a tube to a small pump that provides 80 mm Hg continuous suction.  The pump on the single-use system stays on for 7 days, and then a new pump and dressing are applied. The drainage is held within the dressing either until the dressing is full or at the end of the 7 days. Single-use NPWT is applied in a similar fashion to a silicone foam border and secured with transparent securing strips on all 4 sides to ensure a tight seal and to prevent the dressing from being easily removed. The primary dressing has a silicone layer and silicone border to allow for ease in placement and removal. No canister or large equipment is necessary, and the suction pump is small enough to clip on a waistband or fit into a pocket. A second dressing is included in the application kit and may be used within the 7 days as needed. The suction pump provides a preset negative pressure.⁶ Patients in this article were provided the PICO system (Smith & Nephew). 

The following case reports demonstrate how single-use NPWT was provided to patients under the care of a surgeon and a pediatric wound and ostomy-certified (WOC) nurse to increase patient mobility, decrease the number of dressing changes, and provide an earlier discharge home.

Introduction. The following retrospective case reports involve patients who were followed weekly by both the patients’ surgeon and a WOC nurse. The patients all were less than 17 years old. Traditional NPWT had been used previously but was not a prerequisite for the application of single-use NPWT. Treatment was based on the characteristics of the wound as well as the needs of the patients, who were chosen for this modality related to the need for advanced wound care at home. Concerns related to the parents’ inability to care for the wound were also considered. 

In most cases, parents expressed anxiety about wound care and distrust with outside care providers coming into their homes. In addition, many families did not want to provide wound care at home yet wanted to easily manage care at home between office visits. Single-use NPWT provided a solution to traditional home health nursing care. 

Wound size and/or location was not a deterrent to single-use NPWT. The decision regarding implementation of single-use NPWT was determined as part of the discharge discussion. Patients had to be medically cleared; patients who did not opt for single-use NPWT at home would require admission for wound care.

In all cases, the first single-use NPWT application was provided in the hospital; all subsequent NPWT dressing changes occurred in an outpatient clinic. All wounds contained at least 80% granulation tissue and were no more than 2 cm in depth to comply with the manufacturer recommendations of the chosen single-use NPWT. Parents were given instructions on dressing application and required to provide teachback before hospital discharge. Although weekly office visits were required, parents needed to be able to reinforce the dressing as needed and change the dressing if it became saturated before the next scheduled appointment. Because cost and insurance coverage are an issue for our pediatric patients, our office either absorbed the cost or the patients’ families paid a portion out of pocket.

All photos provided are with the consent of the patient’s parents.

Case 1. An adolescent patient was being treated for bilateral self-injury wounds to her posterior popliteal; the wounds were positive for methicillin-resistant Staphylococcus aureus. Braces were placed on both legs to prevent further injury, allow for placement of wound dressing or a device, and provide stabilization of contracted extremity. NPWT with instillation therapy  using hypochlorous acid was initiated 1 week after admission and for 1 week before application of single-use NPWT. The first application of single-use NPWT was applied during the hospital stay. After 7 days, the dressing was changed and the patient was discharged home with single-use NPWT in place. The patient returned every 7 days to the outpatient plastic surgery clinic for an additional 2 weeks. Single-use NPWT treatment was concluded after 3 weeks. Wounds then were managed with a silicone foam dressing until closure. The issue with the leg in Figure 1 was resolved at the next follow-up; the dehisced wound on the opposite leg remained open after 3 weeks, and then patient was lost to follow-up. The braces prevented flexation at the knee; the patient’s family verbalized the unexpected benefit of decreased pain for the patient related to the inability to keep legs straight (see Figure 1).

Case 2.  An infant was born with dark green tissue on the left lower arm related to a birth-related or intrauterine injury of unknown etiology. The wound was consistent with tissue death; eschar slowly began to form as anticipated, covering the anterior and posterior arm. Surgical management was discussed, but the medical team determined that wound management was preferred over surgical debridement. Autolytic debridement  with conservative sharp debridement and low-frequency ultrasound were initiated with slow but progressive removal of eschar and slough. The parents expressed anxiety over dressing change/removal, saying they did not know if they would be able to care for the wound at home. Once 80% granulation was achieved and the patient was medically cleared for discharge, single-use NPWT was offered and accepted by the family. On the day of discharge, the family was provided teaching with teachback on single-use NPWT. The family returned to the plastic surgery unit every 7 days for dressing changes. After 3 weeks, approximately 80% of epithelial migration had occurred, and daily applications of petrolatum and 3% bismuth tribromophenate were performed at home until closure. Parents were confident in their ability to change the dressings at home (see Figure 2).

Case 3.  The family of an infant with surgical dehiscence after tethered cord repair had difficulty managing the wound, which was located in the gluteal cleft and diaper area. Diapers rubbed the area, and stool wound come in contact with the dressing and wound. The first application of single-use NPWT was performed in the neurosurgery clinic and the patient subsequently was followed weekly. A hydrocolloid ring was placed at the base of the wound just superior to the gluteal cleft to help seal the dressing. The parents were instructed how to apply the seal if needed at home and teachback occurred. After 4 days, the family followed-up in the neurosurgery outpatient clinic for wound check and dressing change; the next follow-up was at 7 days. The wound was resolved 6 days later. No dressing changes were required at home; however, the patient’s parent reinforced the seal several times (see Figure 3).

Single-use NPWT improved the quality of wound care by decreasing the number of dressing changes. Use of traditional NPWT could require dressing changes every other day or every third day and would have meant a longer hospital course. The wounds in these pediatric patients were successfully and safely managed without the need for large equipment and frequent dressing changes. Over-the-counter pain medication was provided by the patients’ caregivers before dressing changes, but no sedation was required with dressing applications and removal. The single-use NPWT assisted in the closure of these patients’ wounds.

Some limitations for use were discovered and should be considered. Large amounts of wound drainage demand more frequent dressing changes. The suction pump only has a 7-day life expectancy; hence, family and professional care providers need to reinforce dressings as needed. Single-use NPWT does not negate the need for follow-up appointments with outpatient clinics for dressing changes, wound assessments, and follow-up.

Single-use NPWT provided to pediatric patients has many benefits. Although parental anxiety was high at the time of hospital discharge in the cases described, parents expressed an ease in use and an overall satisfaction with the therapy. Overall, patients overall had fewer dressing changes than with traditional therapy and changes could be performed with minimal pain medication at weekly outpatient visits. In all cases, wound closure was achieved in 4 weeks or less. 

Next month, we will discuss the proposed mechanisms of action, tips on neonatal use, and my experiences using different NPWT products.