They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:

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Doris Horton
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1 Managing pressure ulcers in neonates, infants, children and young people bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: NICE Pathway last updated: 30 November 2017 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Page 1 of 10

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3 1 Neonate, infant, child or young person with a pressure ulcer No additional information 2 Ulcer measurement and categorisation Measurement Document the surface area of all pressure ulcers in neonates, infants, children and young people, preferably using a validated measurement technique (for example, transparency tracing or a photograph). Document an estimate of the depth of a pressure ulcer and the presence of undermining, but do not routinely measure the volume of a pressure ulcer in neonates, infants, children and young people. Categorisation Categorise each pressure ulcer in neonates, infants, children and young people at onset using a validated classification tool (such as the International NPUAP-EPUAP [2009] Pressure Ulcer Classification System) to guide ongoing preventative and management options. Repeat and document each time the ulcer is assessed. 3 Nutritional supplements and hydration Offer an age-related nutritional assessment to neonates, infants, children and young people with a pressure ulcer. This should be performed by a paediatric dietitian or other healthcare professional with the necessary skills and competencies. Discuss with a paediatric dietitian (or other healthcare professional with the necessary skills and competencies) whether to offer nutritional supplements specifically to treat a pressure ulcer in neonates, infants, children and young people whose nutritional intake is adequate. Offer advice on a diet that provides adequate nutrition for growth and healing in neonates, infants, children and young people with a pressure ulcer. Page 3 of 10

4 Discuss with a paediatric dietitian whether to offer nutritional supplements to correct nutritional deficiency in neonates, infants, children and young people with a pressure ulcer. Assess fluid balance in neonates, infants, children and young people with a pressure ulcer. Ensure there is adequate hydration for age, growth and healing in neonates, infants, children and young people. If there is any doubt, seek further medical advice. 4 Treatment options No additional information 5 Wound management Dressings Consider using a dressing that promotes a warm, moist healing environment to treat grade 2, 3 and 4 pressure ulcers. Consider using topical antimicrobial dressings to treat a pressure ulcer where clinically indicated, for example, where there is spreading cellulitis. Do not offer gauze dressings to treat a pressure ulcer. Neonates Do not use iodine dressings to treat a pressure ulcer in neonates. Negative pressure wound therapy Do not routinely use negative pressure wound therapy to treat a pressure ulcer. Debridement Consider autolytic debridement with appropriate dressings for dead tissue in neonates, infants, children and young people. Consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful. Page 4 of 10

5 The Debrisoft monofilament debridement pad The following recommendations are from NICE medical technologies guidance on the Debrisoft monofilament debridement pad for use in acute or chronic wounds. The case for adopting the Debrisoft monofilament debridement pad as part of the management of acute or chronic wounds in the community is supported by the evidence. The available evidence is limited, but the likely benefits of using the Debrisoft pad on appropriate wounds are that they will be fully debrided more quickly, with fewer nurse visits needed, compared with other debridement methods. In addition, the Debrisoft pad is convenient and easy to use, and is well tolerated by patients. Debridement is an important component of standard woundcare management as described in this interactive flowchart and foot care for people with diabetes. The Debrisoft pad is indicated for adults and children with acute or chronic wounds. The available evidence is mainly in adults with chronic wounds needing debridement in the community. The data show that the device is particularly effective for chronic sloughy wounds and hyperkeratotic skin around acute or chronic wounds. The Debrisoft pad is estimated to be cost saving for complete debridement compared with other debridement methods. When compared with hydrogel, gauze and bagged larvae, cost savings per patient (per complete debridement) are estimated to be 99, 152 and 484 respectively in a community clinic and 222, 347 and 469 respectively in the home. Versajet II hydrosurgery system NICE has published a medtech innovation briefing on the Versajet II hydrosurgery system for surgical debridement of acute and chronic wounds and burns. 6 Friction reduction in young people Parafricta Bootees and Undergarments The following recommendations are from NICE medical technologies guidance on Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers. Parafricta Bootees and Undergarments show potential to reduce the development and progression of skin damage caused by friction and shear in people with, or at risk of, pressure Page 5 of 10

6 ulcers. However, more evidence for their effectiveness in clinical practice is needed to support the case for routine adoption of Parafricta Bootees and Undergarments in the NHS. Research is recommended to address uncertainties about the claimed patient and system benefits of using Parafricta Bootees and Undergarments. This should take the form of comparative research against standard care, preferably carried out in a hospital. The research should include development of criteria to recognise people who would most benefit from the technology in both hospitals and community care. NICE will explore the development of appropriate further evidence, in collaboration with the technology sponsor and with clinical and academic partners, and will update this guidance if and when substantive new evidence becomes available. 7 Pressure redistribution Consider using specialist support surfaces (including dynamic support surfaces where appropriate) for neonates, infants, children and young people with a pressure ulcer, taking into account their current pressure ulcer risk and mobility. Use a high-specification cot or bed mattress or overlay for all neonates, infants, children and young people with a pressure ulcer. If pressure on the affected area cannot be adequately relieved by other means (such as repositioning), consider a dynamic support surface, appropriate to the size and weight of the child or young person with a pressure ulcer, if this can be tolerated. Tailor the support surface to the location and cause of the pressure ulcer. Heel pressure ulcers Discuss with the parents or carers of neonates and infants and with children and young people (and their parents or carers if appropriate), a strategy to offload heel pressure as part of their individualised care plan to manage their heel pressure ulcer, taking into account differences in size, mobility, pain and tolerance. Quality standards The following quality statement is relevant to this part of the interactive flowchart. 8. Pressure redistribution devices Page 6 of 10

7 8 Antimicrobials Consider systemic antibiotics for neonates, infants, children and young people with a pressure ulcer with clinical evidence of local or systemic infection. Discuss with a local hospital microbiology department which antibiotic to offer neonates, infants, children and young people with infection to ensure that the chosen systemic antibiotic is effective against local strains of bacteria. Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer. See what NICE says on antimicrobial stewardship. 9 Interventions that should not be used Do not use the following to treat a pressure ulcer: electrotherapy hyperbaric oxygen therapy. Page 7 of 10

8 Sources (2014) NICE guideline CG179 Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers (2014) NICE medical technologies guidance 20 The Debrisoft monofilament debridement pad for use in acute or chronic wounds (2014) NICE medical technologies guidance 17 Your responsibility Guidelines The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Page 8 of 10

9 Technology appraisals The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Medical technologies guidance, diagnostics guidance and interventional procedures guidance The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties. Page 9 of 10

10 Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Page 10 of 10

Clinical guideline Published: 23 April 2014 nice.org.uk/guidance/cg179

Pressure ulcers: prevention ention and management Clinical guideline Published: 23 April 2014 nice.org.uk/guidance/cg179 NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).