NUTRiTiON SKiN
Adequate nutrition is necessary to promote healing of injuries and provide energy to participate in the rehabilitation process. For many children, refusal to eat may be present, either because of lack of appetite or because this may be the only activity over which they have any control.
Loss of the sense of smell may accompany some injuries, also contributing to anorexia. Nutrition must become a non-negotiable issue during rehabilitation. If the child is unable or unwilling to eat, short-term use of nasogastric tube feedings should be considered. If the inability to eat continues longer, the placement of a gastrostomy tube should be considered. Once a child has finally begun to eat, care must be taken that he or she not overeat and thus become overweight. No calorie guidelines are available for children with SCI, but careful monitoring of weight can assist in determining the correct level of calories necessary for growth without promoting obesity.
Pressure ulcers are a common complication of pediatric SCI and are caused by pressure, shear, and friction, with moisture being a complicating factor. Ulcers cause a huge burden in terms of time lost from school and other activities, cost, and psychological distress. Prevention is clearly a better solution than any treatment. The basis of prevention is thorough education of the child and family about pressure relief, avoiding moisture, and treatment of ulcers in the earliest stage. Data from Model SCI Care Systems in 2006 show that 33.5% of patients developed ulcers while still hospitalized, including 53.4% of those with complete tetraplegia, 39% of those with complete paraplegia, 28.7% of those with incomplete tetraplegia, and 18.3% of those with incomplete paraplegia (34). Fifteen to twenty percent of those seen for annual examinations developed ulcers per year during the first five years after injury. Although these figures may be less in children, ulcers nonetheless are costly. Various systems of classification are used for pressure ulcers (Tables 11.4 and 11.5).
Large pressure ulcers may not heal with the relief of pressure for long periods, and surgery may be necessary. Various types of closures include linear closure and several types of flaps, which are well detailed by Apple and Murray (35).