Pressure ulcer (decubitus ulcer): clinical guidelines

List of Abbreviations

BMI – body mass index

CC – conversion coefficient

NAVC – nail fold capillaroscopy

CT – computed tomography

LDF – laser Doppler flowmetry of vessels (one anatomical region)

LI – laser irradiation

NS – nutritional support

NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs

AMC – arm muscle circumference

MUAC – mid-upper arm circumference

ESR – erythrocyte sedimentation rate

CRP – C-reactive protein

PCT – procalcitonin

SYS – systemic antimicrobial drugs

TSFT – triceps skinfold thickness¹

TEE – total energy expenditure

UHF – ultra-high-frequency therapy

US – ultrasound examination

UVR – ultraviolet radiation

CDP – central Doppler mapping

REE – resting energy expenditure

EN – enteral nutrition

Note:

¹ - According to Order No. 804n of the Russian Ministry of Health dated October 13, 2017, "On Approval of the Nomenclature of Medical Services", the service is designated as "Measurement of skin fold thickness (plycometry)"; it should be noted that the correct definition is skin-fat fold.

Terms and Definitions

Palliative medical care is a set of measures including medical interventions, psychological support, and nursing care aimed at improving the quality of life of incurably ill citizens and directed at relieving pain and other severe manifestations of the disease.

Body mass index (BMI) is an index used to assess the degree to which a person's weight corresponds to their height, and to indirectly judge whether the weight is underweight, normal, or overweight. BMI = body weight / height² (kg/m²).

Mid-upper arm circumference (MUAC) is measured using a flexible tape measure on the non-dominant arm at the midpoint of the upper arm between the acromion and the olecranon process with an accuracy of 1 mm.

Mid-upper arm muscle circumference (MUAMC) – a parameter based on measuring the arm circumference (AC) with a flexible tape measure at the level of the middle third of the non-dominant upper arm and the triceps skinfold thickness (TSFT). It can be used to determine body composition in children with malnutrition. It is calculated using the formula: [(MUAMC = AC (cm) - TSFT (mm + 0.314)].

Enteral nutrition is a type of dietotherapy (nutritional support) that involves the administration of enteral nutrition products via introduction into the gastrointestinal tract in order to fully meet the body's nutrient requirements, including through combination with other types of dietotherapy.

Nutritional support is the process of substrate provision for patients who are unable to take adequate natural nutrition, supplying all essential nutrients for life using special methods and artificially created nutritional formulas (NF) of various orientations.

Prone position (lying on the stomach) is a patient positioning method to facilitate mechanical ventilation in a hospital setting.

Negative pressure wound therapy devices – negative pressure wound therapy device with accessories / Negative pressure wound therapy kit / Negative pressure wound therapy aspirators with accessories / Negative pressure wound therapy apparatus, etc.

Vacuum therapy is a method utilizing a closed drainage system that maintains controlled negative pressure in the wound area (negative pressure wound therapy devices): hydrophilic polyurethane (PU) sponge (wound sponge dressing) with pore size from 400 to 2000 micrometers, transparent adhesive dressing, non-collapsible drainage tubing, and a vacuum source with a fluid collection canister. Negative pressure from –50 to –200 mm Hg is applied; the optimal negative pressure level in the wound is determined individually for each patient and depends on the device used, surface area of the lesion, and depth of the lesion.

Z-SCORE is the standardized deviation of a measurement from the median norm in standard deviation units. It is used to assess children's anthropometric indicators (height, weight, BMI, etc.).

Neurotrophics refers to the regulatory influence of the nervous system on nutrition and metabolism in tissues and organs, ensuring their structural integrity and functions.

Interactive dressings are dressings capable of maintaining a moist environment in the wound, regulating the amount of exudate, and providing conditions for autolytic and reparative processes.

Hydrogel dressings are a type of modern wound dressings consisting of hydrophilic polymers with a high water content.

Alginate dressings are dressings that possess high absorptive capacity and form a gel-like coating that maintains a moist environment and promotes wound cleansing.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Pressure ulcers are defined as inflammatory-dystrophic soft tissue defects arising from prolonged constant pressure combined with other environmental factors (per [1, 2]).

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Pressure ulcers can occur in patients under various conditions and diseases, but are particularly characteristic of patients with impaired neurotrophics and microcirculation.

The most important factors contributing to the formation of pressure ulcers are continuous pressure, shear forces, friction, and moisture.

Risk factors for the development of pressure ulcers:

- prolonged recumbent or sitting position without regular body repositioning / inability to change body position without assistance;

- impact of medical equipment on the skin (masks, catheters, blood pressure cuffs, dressings, intravenous infusion systems);

- medical manipulations and procedures causing limitation of patient mobility (hypnotics and sedatives, prolonged intubation, hypotension, hypoxemia);

- physiological characteristics of children's skin leading to rapid skin trauma;

- contamination of the skin with physiological secretions (feces, urine, sweat);

- malnutrition and/or underweight;

- use of certain medications (glucocorticoids);

- impaired perfusion and reduced tissue oxygenation [1, 2, 3, 4, 5].

Extracorporeal membrane oxygenation is also noted among risk factors in hospitalized children [5].

In the supine position, the highest pressure is exerted on human tissues located in the sacral, gluteal, heel, and occipital regions (40–60 mm Hg); in the prone position (lying on the stomach), up to 50 mm Hg is exerted on the knee and chest areas; in the sitting position with feet supported on a hard surface, the highest pressure (approximately 10 mm Hg) is experienced by tissues in the ischial tuberosity region. The most typical sites of pressure ulcer formation (up to 60% frequency of occurrence) are the sacrum and ischial tuberosities.

The highest incidence of pressure ulcer wounds is observed in patients with various spinal cord pathologies. It has been proven that continuous local pressure on integumentary tissues equal to 40–70 mm Hg/cm² leads to irreversible hypoxic-ischemic cell damage in this area within 1.5–2 hours in this patient group. However, if the pressure force is not constant but varies in a wave-like manner during this time, tissues can withstand pressure up to 240 mm Hg/cm² without damage. The therapeutic effect of anti-decubitus mattresses is based precisely on this phenomenon.

A factor that enhances the effect of direct pressure is the displacement of the skin relative to the underlying tissues, often observed when the patient is in a forced position. For example, when a patient is positioned in bed with the head of the bed raised without a foot support, the patient's body slides downward under the force of gravity. This leads to skin displacement in the sacral and gluteal regions, disruption of regional blood flow due to overstretching and compression, vascular thrombosis, and subsequently tissue necrosis.

Along with this, great importance in the formation of pressure ulcers is attributed to friction, to which the patient's skin is subjected. As a result of such impact, irritation and abrasion of the superficial epidermal layer occur, causing the skin to lose its full protective properties. In particular, it has been revealed that while brief direct local pressure of 160 mm Hg/cm² does not lead to a pressure ulcer, a similar force combined with friction is capable of causing skin ulceration.

Other causes contributing to the occurrence of pressure ulcers include patient malnutrition, skin condition (excessive moisture or dryness), degree of impairment of the patient's motor activity, presence of limb deformities, and ability to maintain personal hygiene (especially in patients with urinary and fecal incontinence).

Violation of patient care rules and techniques, leading primarily to the compression of integumentary tissues, is considered by many specialists to be the main provoking factor in the formation of pressure ulcers.

Undoubtedly, all the above-mentioned factors play an important role in the development of pressure ulcers, but irritation or damage to the autonomic nervous system is considered the primary causal background for this pathology. As a result of pathological changes in the spinal cord, especially its lateral horns at the C8–L1 segments responsible for regulating soft tissue nutrition, there is a loss of adaptive and protective mechanisms and a disruption of humoral regulation, which leads to dyscirculatory disorders and tissue dystrophy. The loss of vasomotor control causes a decrease in vascular tone in paralyzed parts of the body; consequently, pressure on tissues that normally does not impede blood circulation causes their ischemia. This is especially true for immobile and debilitated patients or those who, for one reason or another, are not undergoing rehabilitation. Local pressure that is excessive for the patient, against the background of impaired vascular microcirculation, creates conditions for tissue necrosis, and upon infection, leads to the full clinical picture of a pressure ulcer. Their favored localization is in various anatomical regions associated with bony prominences. During the patient's daily life, these areas are subjected to the greatest intensity and duration of pressure. Such areas include the sacral region, greater trochanters, ischial tuberosities, and calcaneal bones. The literature also reports other, rarer locations for pressure ulcers: the lateral surfaces of the chest, the scapular region, the occiput, etc.

In children, pressure ulcers occur regardless of the level of spinal cord injury, as well as the degree and nature of motor and sensory disorders. The appearance of pressure ulcer lesions has been noted in all age groups, but the size and depth of integumentary tissue defects, and consequently the dynamics of their healing, are more favorable in younger children, all other things being equal. The latter circumstance is most likely associated with the higher reparative capacities of the child's tissues, their plasticity, increased microvascularization of the skin and subcutaneous adipose tissue, the child's greater adaptability to new living conditions associated with immobility, and better care for sick children by others.

1.3 Epidemiology of the Disease or Condition

Pressure ulcers are one of the main problems in inpatient patient care.

According to foreign studies, the incidence of pressure ulcers varies significantly. In general, the prevalence of pressure ulcers in the pediatric population can range from 0.47% to 35%. A higher incidence of pressure ulcers is noted in intensive care units (7–27% among children older than 1 month and 8–16% in newborns).

The incidence of pressure ulcers in children is 14.3/1,000 patient-days.

The incidence of pressure ulcers in patients in contact with medical equipment ranges from 33% to 50%. Therefore, this category of patients should automatically be considered at risk for developing pressure ulcers [1, 2].

The presence of stage 3–4 pressure ulcers in patients increases the risk of mortality by more than 2 times [6, 7].

The pooled incidence rate of pressure ulcers in hospitalized children is 8%, and for medical device-related pressure ulcers, it is 9%; the pooled prevalence rate of pressure ulcers in hospitalized children is 8%, and for medical device-related pressure ulcers, it is 10%. According to an analysis of studies on tracheostomy-related pressure ulcers, the pooled hazard ratio is 0.35 [8].

1.4 Features of Coding the Disease or Condition

L89.0 Decubitus ulcer and pressure area, stage I

L89.1 Decubitus ulcer, stage II

L89.2 Decubitus ulcer, stage III

L89.3 Decubitus ulcer, stage IV

L89.9 Decubitus ulcer and pressure area, unspecified

1.5 Classification of the disease or condition

Table 1. Staging of skin and soft tissue pressure injuries [9].

1.6 Clinical presentation of the disease or condition

Assessment of pressure ulcer severity

Stage I — appearance of a pale skin area or persistent skin erythema that does not resolve after the pressure is relieved; skin integrity is intact. Stage II — appearance of a bluish-red skin color with clear margins; persistent skin erythema; epidermal detachment; superficial (shallow) disruption of skin integrity (a superficial ulcer clinically manifested as an abrasion, blister, or flat crater) extending into the subcutaneous tissue.

Stage III — complete destruction (necrosis) of the skin up to the muscle layer without fascial involvement.

Stage IV — involvement (necrosis) of all integumentary soft tissues; presence of a cavity in which tendons and/or bone structures are visible [10].

Stage V – unstageable pressure ulcer, in cases where epithelial detachment or eschar obscures the assessment of depth of injury.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The criterion for diagnosis is the presence of clinical manifestations described in section 1.6 "Clinical Presentation". Additional methods may be required to diagnose complications, including infection or concomitant/underlying conditions, and to determine indications for supplemental nutrition, therapeutic interventions, etc.

2.1 Complaints and Anamnesis

Complaints and medical history are described in the "Clinical Presentation" section.

For patients with pressure ulcers and impaired microcirculation, the following symptoms are characteristic:

1. Persistent change in skin color.

2. Pain in the affected limb is in most cases the first sign of acute ischemia. A sudden (more often) or gradual (less often) onset, pain intensity, progression, or regression of the pain syndrome. This symptom is absent in patients with spinal cord or peripheral nerve lesions accompanied by sensory impairment.

3. A feeling of numbness, coldness, or paresthesia. These symptoms are also absent in patients with spinal cord or peripheral nerve lesions accompanied by sensory impairment.

2.2 Physical Examination

The most common sites of pressure ulcer formation have age-related characteristics.

For children under 3 years of age, common locations for pressure ulcers are the occipital region, ears, and periauricular region.

By 6–10 years of age, due to changes in body proportions, pressure ulcers begin to occur in typical locations characteristic of adults [11].

Comments: the severity of pressure ulcers is also assessed (see section 1.6).

In addition to local symptoms, the patient's general condition should be assessed and a standard examination performed.

Comments: performed by appropriate specialists depending on the setting of patient diagnosis and treatment.

• In children with pressure ulcers during physical examination, it is recommended to perform regular anthropometry evaluating parameters such as linear height, body weight, mid-upper arm circumference (MUAC), triceps skinfold thickness (TSFT) and subscapular skinfold thickness (SSFT) (Height measurement, Body weight measurement, Mid-upper arm circumference determination, TSFT), as well as body mass index (BMI) calculation to assess the degree of body weight-for-height compliance, and mid-upper arm muscle circumference (MUMC) to characterize the somatic protein pool [17].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: measurement and evaluation of MUAC is preferred in the presence of peripheral edema, ascites, hydrocephalus, or during steroid therapy, when body weight does not reflect nutritional status, including when weighing is impossible due to severity of condition.

Unlike adults, in children it is customary to evaluate not absolute anthropometric values, but the standard deviation score (SDS or Z-score), which shows how many standard (sigma) deviations constitute the difference between the mean value for a given age and sex and the measured value. The degree of deviation will indicate either normal nutritional status values or their disorders (Table 2) [18].

Table 2. Anthropometric parameters of moderate/severe malnutrition in children.

To assess body composition dynamics, bioelectrical impedance analysis can be used (determining the percentage of water, muscle and fat mass, active cell mass, and phase angle) to decide on the need for diet therapy adjustments [19, 20].

2.3 Laboratory Diagnostics

• All patients with pressure ulcers, regardless of stage, are recommended: to undergo a complete blood count (CBC) with differential to assess hemoglobin and leukocyte levels [21, 22].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

Comments: an increase in leukocyte levels above 15 thousand/µL in the complete blood count may indicate the development of infectious complications.

Patients with pressure ulcers frequently develop anemia of chronic disease, which requires ongoing monitoring of hemoglobin levels. Furthermore, impaired tissue oxygenation in anemia can contribute to the onset/progression of pressure ulcers [21, 23].

Comments: serum CRP testing is performed to rule out potential bacterial complications (a diagnostically significant increase is 30–40 mg/L).

o blood albumin testing [21, 22, 23, 119];

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

o blood glucose testing [120];

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

if feasible, serum transferrin testing [119];

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

and, during infusion therapy, blood urea testing [22, 120].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: the results of blood albumin, serum transferrin, and, if performed, blood urea and creatinine tests may be taken into account when deciding on the adjustment of enteral/parenteral nutrition. For details, see the clinical guidelines "Malnutrition in children over 1 year of age (protein-energy malnutrition)".

Comments: for details, see the clinical guidelines "Malnutrition in children over 1 year of age (protein-energy malnutrition)".

Comments: hospitalized children are indicated for initial acid-base balance and blood gas testing, as well as follow-up testing as needed depending on the severity of their condition (upon worsening of the condition, appearance of signs of infection/sepsis); the frequency of testing is determined by the clinical condition and the scope of ongoing therapy—at least once daily, with increased frequency if deviations occur.

Comments: routine procalcitonin (PCT) testing is not performed. Hospitalized patients may be indicated for initial and serial blood procalcitonin testing to rule out systemic spread and/or the development of sepsis, and to monitor the efficacy of antimicrobial therapy.

Comments: patients with stage II-IV pressure ulcers undergo microbiological (culture) examination of skin pressure ulcer aspirate for yeasts, microbiological (culture) examination of wound discharge for fungi (yeasts, molds), and determination of antimicrobial susceptibility (using a tissue fragment if there is no discharge) with determination of susceptibility to antibacterial drugs and bacteriophages, in order to verify the causative agent and correctly prescribe systemic antimicrobial drugs (AMDs). Most frequently isolated microorganisms: Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis, Enterococcus faecalis, Enterococcus faecium, Staphylococcus haemolyticus, Proteus mirabilis, Escherichia coli, Klebsiella species, Citrobacter species, Candida albicans, Morganella morganii, etc. [29].

Interpretation of results is performed according to the guidelines "Determination of antimicrobial susceptibility of microorganisms", 2024 version [30]. In case of a positive culture, to assess treatment efficacy, all patients undergo repeated cultures until three consecutive negative cultures are obtained (obtaining material for bacteriological examination of pressure ulcer aspirate (biopsy specimen), microbiological (culture) examination of pressure ulcer aspirate for aerobic and facultatively anaerobic microorganisms, microbiological (culture) examination of skin pressure ulcer aspirate for yeasts, microbiological (culture) examination of wound discharge for fungi (yeasts, molds), determination of antimicrobial susceptibility (A26.30.004)) at 2-week intervals.

2.4 Instrumental Diagnostics

Comments: hospitalized patients are indicated for ultrasound examination (US) of the pressure ulcer area, including color Doppler mapping (CDM). In outpatient settings, the examination is generally not performed.

• Patients with stage III-IV pressure ulcers are recommended to selectively (as needed, depending on the clinical situation, e.g., in the presence of sepsis or if surgery is planned; when bone is visible in the wound, such studies are generally unnecessary) undergo radiography of the affected skeletal part and/or magnetic resonance imaging (MRI) of the bone tissue (one region) to rule out/timely diagnose sinus tract formation, as well as secondary bone involvement upon development of complications [28].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: Investigations are performed depending on the clinical situation. A pragmatic approach should be followed, especially in patients with severe comorbidities/conditions. In cases where the bone is visible in the wound, investigations are generally unnecessary. In most cases, investigations can influence patient management strategy if the patient has sepsis or if surgery is planned. Computed tomography (CT) is performed when necessary.

The number of anatomical areas to be investigated is determined by the clinical situation.

2.5 Other Procedures

Microcirculation plays a crucial role in oxygen transport to tissues [44]. Its impairment makes adequate tissue supply with oxygen and nutrients, as well as the removal of metabolic products, impossible [43, 45].

The transport of substances necessary for normal vital activity from the blood into the interstitial space depends on the overlapping influence of four groups of factors:

1) the concentration gradient of the transported substance (blood-tissue);

2) the properties of the substance (molecular configuration, molecular weight);

3) the state of the endothelium of exchange microvessels;

4) the hemodynamic factor.

Therefore, all patients with pressure ulcers on the extremities require an assessment of microcirculation. When a local infection develops, both the release of bacterial toxins and local responses to the infectious agent contribute to exacerbating microcirculatory and metabolic disorders in ischemic tissues. The presence of microcirculatory impairment must be taken into account when choosing the treatment strategy for patients [27].

• Children with pressure ulcers / at risk for pressure ulcers are recommended a visual examination in case of microcirculatory pathology to assess capillary refill [46].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: all patients need a capillary refill assessment test, and an Allen test if hand perfusion needs to be evaluated. During the Allen test, the ulnar and radial arteries are compressed, and the patient actively clenches the hand into a fist while releasing the ulnar artery. Normally, pain, pallor, and coolness disappear within 7 seconds. An increase in pain duration beyond 15 seconds indicates significant microcirculatory disorders [47].

Daily pulse oximetry is also used to determine pulsation in the digits.

• Children with pressure ulcers / at risk for pressure ulcers are recommended to undergo pulse oximetry for additional assessment of microcirculation in the extremities [48].

LoR CLE 3Level of Recommendation C (Level of Evidence 3)

Comments: caution should be exercised, as excessive pressure/friction from the pulse oximeter may itself cause a pressure ulcer.

Transcutaneous partial oxygen pressure monitoring may be used [49].

• Children with pressure ulcers are recommended, where possible, initial and follow-up appointments (examinations, consultations) with a clinical dietitian, as well as the participation of a medical speech-language pathologist (medical-speech-language assessment for dysphagia, medical-speech-language procedure for dysphagia) to assess nutritional status and the possibility of enteral nutrition [52].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: all patients with pressure ulcers require a high-calorie diet with an increased protein content (in the absence of contraindications). Micronutrient supplementation is mandatory (according to physiological needs or identified deficiency). The type and amount of enteral nutrition must be constantly reviewed to avoid calorie and nutrient deficits.

For a detailed assessment of nutritional status, see the clinical guidelines "Malnutrition (protein-energy malnutrition)."

Comments: pressure ulcers are painful.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The goal of pressure ulcer treatment is the restoration of normal skin in the area of the defect. Regardless of the treatment method, great attention should be paid to properly organized care: strict adherence to asepsis (wound infection significantly slows down pressure ulcer healing), frequent repositioning of the patient, the use of anti-decubitus mattresses, other special devices or beds, prevention of trauma to the granulation tissue of the pressure ulcer wound, adequate nutrition with a sufficient amount of proteins and vitamins; and proper hygienic care of the patient [10].

Basic principles of pressure ulcer treatment:

1) the principle of matching the prescribed therapy to the stage of the process;

2) the principle of a multimodal approach (combination of various methods of influencing the wound healing process) [22].

Treatment of pressure ulcers depends on the stage of the disease. The treatment algorithm for pressure ulcers in children is presented in Appendix B1.

3.1 Dietotherapy and nutritional support

Dietotherapy must be an integral part of the comprehensive approach to pressure ulcer treatment, since their formation is accompanied by catabolic processes, protein loss due to the destruction of own tissues, often combined with insufficient intake of protein and other macro- and micronutrients.

• Against the background of restricted physical activity, children with pressure ulcers / at risk for pressure ulcers are recommended to undergo an individual calculation of the energy value of the diet based on the results of direct or indirect calorimetry, taking into account current anthropometric parameters (body weight and height), muscle tone, degree of malnutrition, metabolic disorders, and the scope of rehabilitation measures in order to prescribe adequate nutritional support (Appendix A3.3-A3.5) [55].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: the method of direct calorimetry consists in determining resting energy expenditure by the rate of oxygen consumption and the rate of carbon dioxide elimination (each liter of oxygen corresponds to a certain amount of energy). Based on the obtained indicators, the rates of endogenous oxidation of proteins, fats, and carbohydrates are assessed, and the basal energy expenditure (BEE) is calculated.

• If it is not possible to determine basal metabolism by direct calorimetry in children with pressure ulcers / at risk for pressure ulcers, it is recommended to use the Schofield, Harris-Benedict, and other formulas to determine BEE (Appendix A3.3, A3.4, A3.5) [56, 57, 58].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: an increase in the daily caloric intake of the diet is influenced by the presence of comorbid pathology: fever, trauma, infectious process, malabsorption, pain, hypertonus, and seizures – upon identification of which, upward correction coefficients for energy requirements are introduced. Energy expenditure (kcal/day) = BEE × comorbid pathology coefficients (Appendix A3.6) [56, 57, 58].

Comments: the presence of pressure ulcers refers to conditions with increased energy demand. Insufficient protein and energy intake impedes healing processes and the fight against wound infection.

A key role in the treatment of pressure ulcers is played by the intake of protein and essential amino acids, as they participate in reparative processes at all stages of wound healing: from cell proliferation to collagen synthesis and immune response. Dietary protein content, should be increased to 2.5–3.0 g/kg/day and 3.0–4.0 g/kg/day depending on age, pressure ulcer stage, and comorbid pathology, controlled by serum urea levels. It is necessary to recalculate the caloric intake of the diet taking into account the dynamics of anthropometric indicators and comorbid pathology at least once a month.

Comments: ER is the most physiological, providing intraluminal trophic support to the gastrointestinal mucosa, preventing bacterial translocation and the development of sepsis.

When organizing oral nutrition, the energy value and macronutrient composition of the diet should be ensured using natural foods, as well as by prescribing nutritional support using specialized nutritional products during additional meals.

The choice of enteral nutrition method is determined by the preservation of swallowing function and the functional state of the gastrointestinal tract: decreased appetite, lack of desire to eat, presence of oromotor disorders, severe dysphagia, or recurrent aspiration bronchopneumonia are indications for nasogastric tube placement. If tube feeding is required for more than 6 weeks, gastrostomy placement is indicated [57].

• For patients with pressure ulcers in the absence of food intolerance, it is recommended to use specialized, high-protein, iso-/hypercaloric enteral formulas via sipping; if feasible—for children aged 3 years and older—a specialized medical nutritional product, liquid formula for enteral nutrition (enriched with arginine, zinc, selenium, and antioxidants) under tolerance monitoring. In the presence of malabsorption phenomena and intolerance to polymeric enteral formulas, the issue of prescribing a therapeutic formula based on hydrolyzed proteins (semi-elemental/oligomeric formulas) should be considered in order to correct and maintain optimal nutritional status [60, 61, 62, 63, 64].

GCR CLEL 2Grade of Recommendation C (Level of Evidence 2)

Comments: in practice, additional supplementation with nutritional additives containing arginine, glutamine, zinc, and selenium is also used to support cellular proliferation and repair.

o Insufficient nutrient intake "by mouth", refusal to eat;

o Inability to cover 60-80% of the daily energy requirement for 10 days or more;

o Total meal time exceeding 4-6 hours per day, duration of a single feeding exceeding 30 minutes;

o Absence of weight gain or insufficient weight and/or height gain against the background of an adequately formulated diet and nutritional support:

- more than 1 month in children under 2 years of age;

- for 3 months in children older than 2 years of age;

o Negative dynamics of weight-for-age Z-Score by 2 or more standard deviations against the background of adequate caloric intake of the diet, taking into account age, gender, anthropometric indicators, and adequate nutritional support [61, 65, 66, 67].

Level of Evidence CGrade of Recommendation 5Level of Evidence C (Level of Confidence 5)

• For children with pressure ulcers receiving tube/gastrostomy feeding, it is recommended to use an enteral formula as the primary source of nutrition, since this method of nutrition organization is more optimal compared to a general minced/pureed diet, promotes full provision of macro-, micronutrients and energy, creating conditions for anabolic processes and repair in order to correct and maintain optimal nutritional status [61, 65, 68].

GCR CLEL 2Grade of Recommendation C (Level of Evidence 2)

Comment: the selection of the enteral formula is carried out individually, taking into account nutritional status indicators, the absence or presence of gastrointestinal symptoms, and comorbid pathology. Polymeric high-protein iso- or hypercaloric nutritional formulas are the product of choice in children with pressure ulcers. The daily volume of the enteral formula is determined based on the individually calculated protein and energy requirement norms.

The duration of nutritional support is determined by the physician individually, taking into account therapeutic efficacy [51, 58].

Comments: parenteral lipid intake should be limited to a maximum of 3 g/kg/day in older children. Administration of lipids should be started at lower doses, increasing the volume to calculated values over 3-4 days, with control evaluation of laboratory parameters (triglycerides) [57].

3.2 Conservative treatment

3.2.1 Dressings

Dressings (wound coverings) are special materials that protect the wound from microorganisms and create optimal conditions for tissue healing, and do not irritate or traumatize the area around the wound.

3.2.1.1 Dressings for stage I pressure ulcers

- film dressing - applied for up to 7 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash. In some cases, it causes contact dermatitis (in case of an allergic reaction to the adhesive).

- Hydrogel dressing - applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash.

- Atraumatic net/mesh dressings: applied for 1-2 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: dense cotton mesh impregnated with a medicinal substance or antiseptics and disinfectants. Function depends on the active substance of the agent with which the dressing is impregnated. A rigid mesh structure can cause tissue ischemia - the patient must not be turned onto the area where a dressing of this type is applied.

3.2.1.2 Dressings for stage II pressure ulcers

Inflammatory phase:

- Hydrogel dressing applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash.

- Film dressing - applied for up to 7 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: durable polyurethane self-adhesive film. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash. In some cases, it causes contact dermatitis (in case of an allergic reaction to the adhesive).

- Hydrocolloid dressing - applied for 3-5 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: self-adhesive absorbent dressings with a semi-permeable covering layer that is impermeable to bacteria and water. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash. In some cases, they cause contact dermatitis (reaction to the adhesive).

- Atraumatic net/mesh dressings: applied for 1-2 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: function depends on the active substance of the agent with which the dressing is impregnated. A rigid mesh structure can cause tissue ischemia - the patient must not be turned onto the area where a dressing of this type is applied.

- Wound-healing dressings: applied for 1-3 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: impregnated with a wound-healing ointment/solution. Function depends on the active substance of the agent with which the dressing is impregnated. A rigid mesh structure can cause tissue ischemia - do not turn the patient onto the area where a dressing of this type is applied.

Granulation phase:

- Wound-healing dressings: applied for 1-3 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: impregnated with a wound-healing ointment/solution. Function depends on the active substance of the agent with which the dressing is impregnated. A rigid mesh structure can cause tissue ischemia - do not turn the patient onto the area where a dressing of this type is applied.

- Antiseptic dressings: applied for 1-3 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Wound cleansing:

Epithelialization and scarring phase:

- Hydrogel dressing (except for amorphous gel) applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash.

- Film dressing: applied for up to 7 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: durable polyurethane self-adhesive film. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash. In some cases, it causes contact dermatitis (due to an allergic reaction to the adhesive).

- Hydrocolloid dressing (excluding amorphous gel): applied for 3–5 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: self-adhering absorbent dressings with a semipermeable, bacteria- and waterproof top layer. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash. In some cases, they cause contact dermatitis (reaction to the adhesive).

- Antiseptic dressings: applied for 1–3 days (impregnated with an antiseptic solution containing chlorhexidine**; water-based antiseptic, sterile gauze/non-woven pad, and adhesive plaster) (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment:

- Inactive dressings: sterile gauze/non-woven pad and adhesive plaster (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Wound cleansing:

3.2.1.3 Dressings for stage III pressure ulcers

Stage III

Inflammatory phase:

- Hydrogel dressing (excluding amorphous gel): applied with a replacement interval of 1–3 days and 5–7 days under a film dressing (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash.

- Film dressing: applied for up to 7 days [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: durable polyurethane self-adhesive film. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash. In some cases, it causes allergic contact dermatitis (due to an allergic reaction to the adhesive).

- Alginate dressings: applied for 1–3 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: made mainly from seaweed derivatives, with fibers woven into ropes or sheets. Calcium alginate dissolves upon contact with wound exudate and normally forms a yellow gel with an unpleasant odor. It has mild hemostatic properties. Do not use on low-exudate and dry wounds. Timely dressing changes are necessary due to adhesion to the wound surface. Tissue trauma and capillary bleeding may occur upon dressing removal.

- Hydroactive dressings: applied into wound pockets (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Foam dressings: applied for 3–5 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: elastic polyurethane top layer, inner soft absorbent polyurethane foam.

- Absorbent and superabsorbent dressings: applied for 1–3 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: multilayer dressing with a polypropylene backing. Contains a non-adhering two-layer non-woven material, a fluff pulp sorption pad, a thin paper pad, and a water-repellent cellulose coating on the outer side of the dressing. Acts as a secondary dressing (applied over the primary one).

- Wound-healing dressings: applied for 1–3 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: impregnated with a wound-healing ointment/solution. Function depends on the active substance of the product with which the dressing is impregnated. The rigid mesh structure can cause tissue ischemia — do not position the patient on the area where this type of dressing is applied.

- Vacuum dressing application (wound sponge dressing) using a negative pressure wound therapy device (see section "Terms and Definitions") to the affected area (vacuum therapy) (application of a dressing in case of compromised skin integrity) [122, 123, 124].

LoR CGoE 4Level of Recommendation C (Grade of Evidence 4)

Comments: used optionally.

Granulation phase:

- Hydrogel dressing applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash.

- Film dressing - applied for up to 7 days (Application of a dressing in case of violation of the integrity of the skin) [70].

GoE 5Level of Recommendation (Grade of Evidence C, 5)

Comments: durable polyurethane self-adhesive film. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash. In some cases, it causes contact dermatitis (due to a reaction to the adhesive).

- Alginate dressings: applied for 1–3 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: made mainly from seaweed derivatives, with fibers woven into ropes or sheets. Calcium alginate dissolves upon contact with wound exudate and normally forms a yellow gel with an unpleasant odor. It has mild hemostatic properties. Do not use on low-exudate and dry wounds. Timely dressing changes are necessary due to adhesion to the wound surface. Tissue trauma and capillary bleeding may occur upon dressing removal.

- Atraumatic net/mesh dressings: applied for 1-2 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comment: function depends on the active substance of the product with which the dressing is impregnated. The rigid mesh structure can cause tissue ischemia — do not position the patient on the area where this type of dressing is applied.

- Wound-healing dressings: applied for 1–3 days (application of a dressing in case of compromised skin integrity). Dioxomethyltetrahydropyrimidine + chloramphenicol (ointment for external use) (from 1 year of age), dioxomethyltetrahydropyrimidine (ointment for external and local use, use with caution in children under 3 years of age), dexpanthenol, povidone-iodine ointment for external use 10%, chloramphenicol (solution for external use [alcoholic] (use with caution in young children), chloramphenicol [D,L] liniment (from 4 weeks of age)) (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: impregnated with a wound-healing ointment/solution. Function depends on the active substance of the agent with which the dressing is impregnated. A rigid mesh structure can cause tissue ischemia - do not turn the patient onto the area where a dressing of this type is applied.

- Antiseptic dressings: applied for 1–3 days (impregnated with an antiseptic solution containing chlorhexidine**; water-based antiseptic + sterile gauze/non-woven pad + adhesive plaster) (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Vacuum dressing application (wound sponge dressing) using a negative pressure wound therapy device to the affected area (vacuum therapy) (application of a dressing in case of compromised skin integrity) [122, 123, 124].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

Comments: used optionally.

Epithelialization and scarring phase:

- Antiseptic dressings: applied for 1–3 days (impregnated with an antiseptic solution containing chlorhexidine** (water-based antiseptic, sterile gauze/non-woven pad, and adhesive plaster)) (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Interactive dressings: sterile gauze/non-woven pad + adhesive plaster (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Hydrogel dressing (excluding amorphous gel): applied with replacement intervals of 1–3 days and 5–7 days under a film dressing [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash.

- Film dressing: applied for up to 7 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: durable polyurethane self-adhesive film. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash. In some cases, it causes contact dermatitis (in case of an allergic reaction to the adhesive).

- Hydrocolloid dressing (excluding amorphous gel): applied for 3–5 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: self-adhering absorbent dressings with a semipermeable, bacteria- and waterproof top layer. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash. In some cases, they cause contact dermatitis (reaction to the adhesive).

- Interactive dressings: sterile gauze/non-woven pad + adhesive plaster (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Vacuum dressing application (wound sponge dressing) using a negative pressure wound therapy device to the affected area (vacuum therapy) (application of a dressing in case of compromised skin integrity) [122, 123, 124].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3)

Comments: used optionally.

3.2.1.4 Dressings for stage IV pressure ulcers

Inflammatory phase:

- Hydrogel dressing (except for amorphous gel) applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash.

- Film dressing: applied for up to 7 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: durable polyurethane self-adhesive film. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash. In some cases, it causes contact dermatitis (in case of an allergic reaction to the adhesive).

- Hydroactive dressings (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Foam dressings: applied for 3–5 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: elastic polyurethane top layer, inner soft absorbent polyurethane foam.

- Absorbent and superabsorbent dressings: applied for 1–3 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: multilayer dressing with a polypropylene backing. Contains a non-adhering two-layer non-woven material, a fluff pulp sorption pad, a thin paper pad, and a water-repellent cellulose coating on the outer side of the dressing. Acts as a secondary dressing (applied over the primary one).

- Vacuum dressing application (wound sponge dressing) using a negative pressure wound therapy device to the affected area (vacuum therapy) (application of a dressing in case of compromised skin integrity) [122, 123, 124].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

Comments: all patients with stage IV pressure injuries are indicated for surgical treatment. In the postoperative period, after the removal of necrotic tissue, vacuum therapy may be performed, followed by skin grafting (see section 3.3).

Granulation phase:

- Hydrogel dressing applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash.

- Film dressing - applied for up to 7 days (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: durable polyurethane self-adhesive film. Untimely replacement of the dressing or application to a wound with a high level of exudation can cause maceration and diaper rash. In some cases, it causes contact dermatitis (in case of an allergic reaction to the adhesive).

- Alginate dressings: applied for 1–3 days (Application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: mostly made from seaweed derivatives, with fibers woven into ropes or sheets. Calcium alginate dissolves upon contact with wound exudate, normally forming a yellow gel with an unpleasant odor. Possesses mild hemostatic properties. Do not use on low-exudate and dry wounds. The dressing must be changed in a timely manner due to adhesion to the wound surface. Tissue trauma and capillary bleeding may occur when removing the dressing.

- Wound-healing dressings: applied for 1–3 days. Dioxomethyltetrahydropyrimidine + chloramphenicol (ointment for topical use) (from the age of 1 year), dioxomethyltetrahydropyrimidine (ointment for topical and local use, use with caution in children under 3 years), dexpanthenol, povidone-iodine ointment for topical use 10%, chloramphenicol (solution for topical use [alcoholic] (use with caution in young children), chloramphenicol [D,L] liniment (from 4 weeks) (Application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: impregnated with a wound-healing ointment/solution. Function depends on the active substance of the agent with which the dressing is impregnated. A rigid mesh structure can cause tissue ischemia - do not turn the patient onto the area where a dressing of this type is applied.

- Vacuum dressing application (wound sponge dressing) using a negative pressure wound therapy device to the affected area (vacuum therapy) (application of a dressing in case of compromised skin integrity) [122, 123, 124].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comments: all patients with stage IV pressure injuries are indicated for surgical treatment. In the postoperative period, after the removal of necrotic tissue, vacuum therapy may be performed, followed by skin grafting (see section 3.3).

Epithelization phase:

- Hydrogel dressing applied at replacement intervals of 1-3 days and 5-7 days under a film dressing (Application of a dressing in case of violation of the integrity of the skin) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: hydrogel dressings are semi-occlusive and consist of complex hydrophilic polymers with a high (90%) water content. Untimely dressing changes or application to a wound with a high level of exudation may cause maceration and skin diaper rash.

- Film dressing: applied for up to 7 days (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: durable polyurethane self-adhesive film. Untimely dressing replacement or application to a highly exudative wound may cause maceration and diaper rash. In some cases, causes allergic contact dermatitis (in case of an allergic reaction to the adhesive).

- Hydrocolloid dressing (excluding amorphous gel) applied for 3–5 days (Application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments: self-fixing absorbent dressings with a semi-permeable, bacteria- and water-impermeable cover layer. Untimely dressing replacement or application to a highly exudative wound may cause maceration and diaper rash. In some cases, cause contact dermatitis (reaction to the adhesive).

- Interactive dressings: sterile gauze/non-woven pad + adhesive plaster (application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

- Antiseptic dressings: applied for 1–3 days (impregnated with an antiseptic solution containing chlorhexidine**; water-based antiseptic + sterile gauze/non-woven pad + adhesive plaster) (Application of a dressing in case of compromised skin integrity) [70].

gRC CLoE 5Grade of Recommendation C (Level of Evidence 5)

Comments:. [70].

- Application of a vacuum dressing (wound sponge dressing) using a negative pressure wound therapy device to the affected area (negative pressure wound therapy) (Application of a dressing in case of compromised skin integrity) [122, 123, 124..

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

Comments: all patients with stage IV pressure injuries are indicated for surgical treatment. In the postoperative period, after the removal of necrotic tissue, vacuum therapy may be performed, followed by skin grafting (see section 3.3).

3.2.2 Treatment of infectious complications of pressure ulcers (decubitus ulcers)

Antibacterial therapy:

Comments: local bacterial load should be monitored to prevent the transition from colonization to infection.

• If there are changes in the complete blood count (CBC) in the form of leukocytosis, neutrophilia, elevated CRP or PCT levels, and/or highly probable clinical signs of infection, it is recommended to prescribe systemic antimicrobial drugs to children with pressure ulcers in order to arrest infectious inflammation [97, 121].

GCR BLOC 1Grade of Recommendation B (Level of Evidence 1)

Comments: treatment is prescribed empirically, with subsequent adjustment based on culture results. In an outpatient setting, oral administration of systemic antibacterial drugs is more often possible; in a hospital setting, parenteral administration is used if oral administration is not feasible or if indicated.

Comment: preference should be given to water-based antiseptics and disinfectants.

3.2.3 Infusion therapy

Comments: infusion therapy should be carried out with daily monitoring of blood electrolytes (blood potassium level test, blood sodium level test), biochemical parameters (blood glucose level test, total blood protein level test, blood albumin level test, blood urea level test, blood creatinine level test), acid-base balance and blood gas test, and hemodynamic parameters (heart rate measurement, peripheral blood pressure measurement, central venous pressure measurement, SatO₂ [pulse oximetry]), mandatory recording of urine output (urine volume determination) and pathological fluid losses (perspiration, hyperthermia). For details, see the clinical guidelines "Protein-Energy Malnutrition".

3.2.4 Pain management

Pain management is performed based on the clinical situation, including taking into account clinical guidelines for pain in children.

3.3 Surgical Treatment

Indications:

1. Failure of complex conservative therapy.

2. Long-standing pressure ulcers with an area greater than 60 cm².

3. Formation of a trophic ulcer.

Contraindications:

1. Severe patient intoxication, hypoproteinemia, anemia.

2. Necrotic-inflammatory stage of the pressure ulcer [22].

The following surgical techniques are used for treatment:

1) split-skin grafting;

2) excision of the pressure ulcer followed by local tissue plasty;

3) excision of the pressure ulcer followed by plasty with transposed skin, musculocutaneous, and myocutaneous flaps;

4) excision of the pressure ulcer followed by plasty with a transposed pedicle skin or myocutaneous flap [82].

Comments: tubular drainage (sterile disposable suction drainage) connected to an active suction system for 2–3 days. For extensive defects with a soft-tissue plastic material deficit and the likelihood of local inflammation, a flow-wash drainage system (sterile single-use active wound drainage device) is installed for 4–6 days.

• After the removal of neactively altered tissues (necrectomy) and upon receiving a positive culture result (for services see cl. 2.3: obtaining material for bacteriological examination of a pressure ulcer punctate [biopsy specimen], microbiological [cultural] examination of a pressure ulcer punctate for aerobic and facultatively anaerobic microorganisms, microbiological [cultural] examination of a skin pressure ulcer punctate for yeast fungi, microbiological [cultural] examination of wound discharge for fungi [yeast, mycelial], determination of microorganism susceptibility to antimicrobial chemotherapeutic drugs), all children with pressure ulcers are recommended to undergo antibiotic therapy (see conservative treatment section), with a control culture (for services see cl. 2.3) in 2 weeks in order to arrest the infectious process [85, 90, 128, 129].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: antibiotic therapy is carried out against the background of local treatment. To proceed to the next stage – skin grafting, it is necessary to obtain three consecutive negative cultures, as well as the presence of "viable" granulations. If the acute phase of the ulcerative process has resolved, surgical treatment must be performed.

• Following the removal of necrotically altered tissues (necrectomy), it is recommended that all pediatric patients with pressure ulcers undergo split-thickness skin grafting / pressure ulcer excision followed by local tissue flap surgery / pressure ulcer excision followed by transposition of skin, musculocutaneous, or fasciocutaneous flaps / pressure ulcer excision followed by transposition of a skin or musculocutaneous pedicled flap to ensure adequate blood supply to the defect areas [86, 87].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: Reverdin, Thiersch, Davis, and Humby techniques are used. If the size of a deep pressure ulcer does not decrease by 30% within 2 weeks of conservative treatment, it is necessary to consider reassessing the patient's condition and changing the treatment tactics.

Comment: the decision is made depending on the clinical situation.

Comments: altered soft tissues are removed radically, taking into account that subcutaneous tissue and muscles in pressure ulcers are affected over a wider area than the skin lesion itself. Underestimation of this factor may lead to flap failure. U-shaped sutures with rubber tubular pads are applied by stitching all soft tissue layers with wide stitches, stepping back 1.5–2 cm from the wound edge along its entire length. This tactic aims to evenly distribute the load on the sutures along the entire length of the wound during the adaptation of its edges and maintain normal blood circulation within them.

3.4 Other treatment

Comment: anti-decubitus mattresses can be used regardless of the pressure ulcer stage, in an outpatient setting or in a hospital.

Contraindications may include conditions where this intervention could be hazardous:

- newborns on mechanical ventilation,

- children with spinal cord injury,

- children with head injury [90].

Trypsin + Chymotrypsin (in accordance with the instructions) [22].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Physiotherapeutic treatment methods.

The use of physiotherapeutic methods should be a component of the comprehensive treatment of pressure ulcers in patients with stage II–IV. Physiotherapeutic exposure reduces the bacterial load of the wound with pathogenic microorganisms. Along with this, it improves blood circulation and trophism in the surrounding tissues, contributing to the rapid closure of the pressure ulcer.

Inflammatory phase:

- application of ultra-high frequency (UHF) currents to the skin [22, 91, 132].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comment: UHF therapy is administered at a dose of 15–20 W around the pressure ulcer for 10 minutes daily for 5–10 days [91]: it induces deep hyperemia, increases the activity of the reticuloendothelial system, and enhances phagocytosis.

or

- ultraviolet irradiation of the skin (UVI). Local long-wave ultraviolet therapy [22, 132].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comment: directly onto the wound surface and the skin around the pressure ulcer, starting with three biodoses, adding half a biodose daily, with a course of 8–12 procedures [92]. Long-wave UVI is predominantly used as it has the greatest biological directional effect.

or

- low-level laser irradiation (LI) of the skin [92].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comment: for treatment, a physiotherapeutic helium-neon laser device with an output power of 0.015 W (= 630 nm) or a laser device operating in the IR spectrum range (= 830 nm) (ophthalmic helium-neon laser device) is used.

Granulation phase:

- low-level laser irradiation (LI) of the skin [92].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Epithelialization phase:

- ultrasonic skin treatment (sonication intensity is set within 1.5 W/cm². In the epithelialization stage, intensity is reduced to 0.8–1 W/cm². The duration of sonication averages 1.2–3 min. The duration of treatment is gradually increased. A course consists of 6–10 procedures) [22, 94, 97, 133].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: ultrasound has a varying degree of acoustic propagation in living and necrotic tissue, which promotes the rapid rejection of necrosis areas within the ulcer. Sound pressure oscillations produce tissue micromassage, thereby altering blood and lymph circulation conditions, making the tissue more elastic [94].

or

- low-level laser irradiation (LI) of the skin [22, 92].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: for application, see the "inflammatory phase" section.

- infrared radiation therapy [92].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

or

- darsonvalization for microcirculatory disorders (power 60–80 W, gap 1 cm, transverse, 15 min daily) [98].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: [98].

or

- ultraviolet irradiation of the skin (UVI). Local long-wave ultraviolet therapy [98].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comment: for application, see the "inflammatory phase" section.

or

- drug electrophoresis for microcirculatory disorders in children with stage I–II pressure ulcers: zinc electrophoresis (0.1–0.25% zinc sulfate solution (a medicinal product prepared by a pharmacy organization)): the active electrode is moved directly onto the pressure ulcer, the indifferent electrode is placed directly on the pressure ulcer, or indifferent-transversely; the current intensity is determined depending on the size of the trophic defect at a rate of 0.05 mA per 1 cm² for 15–20 min daily, with a course of 7–10 procedures [98].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable.

5. Prevention and Dispensary Observation

5.1 Preventive measures

Preventive measures should be aimed at:

- reducing pressure on bone tissues;

- preventing tissue friction and shear during patient repositioning or incorrect positioning ("sliding" from pillows, "sitting" position in bed or in a armchair);

- monitoring the skin over bony prominences;

- maintaining skin cleanliness and moderate moisture (not too dry and not too moist);

- providing the patient with adequate nutrition and hydration;

- teaching the patient self-help techniques for repositioning;

- educating caregivers.

Comments: it is necessary to avoid excessive skin moisture in patients, and prevent biological fluids (feces, urine, vomit) from getting onto and staying on the skin.

Comments: the use of medical equipment in a patient that is not appropriate for age, size, and purpose may pose a risk of pressure ulcers. The use of makeshift or adapted medical equipment is unacceptable.

Comments: the feasibility of rotation is determined by the type of medical device and the clinical situation.

Comment: due to the fact that the use of these medical devices in this age group increases the risk of skin epithelial damage and, consequently, the development of pressure injuries.

Comment: they can be used regardless of the stage of pressure injuries, in an outpatient setting or in a hospital.

Contraindications may include conditions where this intervention could be hazardous:

- newborns on mechanical ventilation,

- children with spinal cord injury,

- children with head injury [90].

6. Organization of Medical Care

Medical care for children with pressure injuries or at risk for pressure injuries can be provided in any setting stipulated by the legislation of the Russian Federation, for example:

- inpatient (in conditions providing round-the-clock medical observation and treatment);

- on an outpatient basis (under conditions not providing for round-the-clock medical observation and treatment);

- day inpatient (in conditions providing medical observation and treatment during the day, not requiring round-the-clock medical observation and treatment).

Specialized medical care for children with pressure injuries or at risk for pressure injuries can be provided in any inpatient departments, most frequently required in intensive care units (by anesthesiologists-resuscitators, neonatologists, pediatricians, neurologists, pediatric surgeons, etc.).

Primary health care for children is provided in outpatient settings and day inpatient settings.

Primary pre-medical health care for children is provided by medical workers with secondary medical education.

Primary medical health care for children is provided by a district pediatrician / general practitioner (family physician).

Primary specialized health care is provided by a dermatovenereologist, when possible by a dietitian, and when necessary by a pediatric surgeon (upon suspicion or detection of stage 3 or higher pressure injuries in children, pediatricians, general practitioners (family physicians), palliative care physicians, and others refer children for a consultation with a pediatric surgeon).

Palliative medical care for children can be provided in outpatient settings, including at home, in day inpatient settings, and in inpatient settings.

Emergency medical care, including specialized emergency medical care, for children requiring urgent medical intervention is provided by paramedic out-of-hospital emergency teams and physician out-of-hospital emergency teams.

If there are medical indications, the treatment of children is carried out with the involvement of necessary medical specialists.

Routine medical care is provided for pressure injuries not accompanied by a threat to the children's life and not requiring emergency or urgent medical care.

Indications for hospitalization in a medical organization:

1. Presence of stage III–IV pressure injuries.

2. Development of an infection syndrome, both according to laboratory parameters and symptomatically, including children at risk for sepsis—when there is a need for inpatient medical care.

3. Inability to provide the necessary medical care in an outpatient setting.

Indications for patient discharge from a medical organization:

1. Relief of the condition or completion of the course of treatment in the established manner.

2. Relief of the infectious process, absence of data indicating systemic inflammatory response syndrome.

Additional aspects of organizing care for children with pressure injuries

The management of children with pressure injuries is multidisciplinary in nature and requires close interaction among specialists of various profiles.

An important task of medical organizations is the continuous support of the child—from initial diagnosis to specialized and palliative care, as well as follow-up observation after discharge.

Thus, the medical care system for children with pressure injuries in Russia is built on a multi-level approach: from outpatient monitoring (including by visiting pediatric palliative care teams) to inpatient treatment (including in pediatric palliative care departments and children's hospices). Hospitalization is carried out according to indications, length of stay is individual, and repeated and planned hospitalizations are possible. Treatment requires the participation of pediatricians / district pediatricians / neonatologists / general practitioners (family physicians), pediatric surgeons, anesthesiologists-resuscitators, palliative care physicians, and secondary medical personnel, as well as the active involvement of the family.

7. Additional Information

Risk factors for an unfavorable outcome of surgical treatment in patients with pressure injuries:

• development of infectious complications;

• concomitant systemic diseases;

• immunodeficiency states;

• cachexia;

• oncological disease;

• non-compliance with other recommendations of the attending physician.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Ambarchyan E.T. – Candidate of Medical Sciences, Member of the Union of Pediatricians of Russia.

Anikina D.D. – Dermatovenereologist at the Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2) of the Ministry of Science and Higher Education of the Russian Federation, Member of the Union of Pediatricians of Russia.

Artemyeva S.I. – Member of the National Alliance of Dermatovenereologists and Cosmetologists, Researcher at the Department of Clinical Dermatovenereology and Cosmetology, Dermatovenereologist at the Specialized Medical Care Department of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Assistant Professor at the Department of Dermatovenereology and Allergology with a Course in Immunology, Medical Institute of the Peoples' Friendship University of Russia (RUDN University).

Baranov A.A. – Academician of the Russian Academy of Sciences, Professor, Doctor of Medical Sciences; Honorary President of the Union of Pediatricians of Russia, Advisor to the Head of the Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2), Professor at the Department of Pediatrics and Pediatric Rheumatology, N.F. Filatov Institute of Children's Health, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Chief Freelance Pediatrician of the Russian Ministry of Health.

Batysheva T.T. – Professor, Doctor of Medical Sciences, President of the Association of Pediatric Rehabilitologists of Russia, Director of the Scientific and Practical Center for Children's Psychoneurology of the Moscow Healthcare Department, Head of the Department of Pediatric Neurology, Physical and Rehabilitation Medicine, Faculty of Continuous Medical Education, Medical Institute of RUDN University, Chief Freelance Pediatric Rehabilitologist of the Russian Ministry of Health, Honored Doctor of Russia.

Belyaeva I.A. – Doctor of Medical Sciences, Head of the Department of Preconceptional, Antenatal, and Neonatal Medicine, Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2), Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatricians of Russia, Honorary Professor of the Russian Association of Perinatal Medicine Specialists.

Bombardirova E.P. – Doctor of Medical Sciences, Professor, Chief Researcher at the Department of Preconceptional, Antenatal, and Neonatal Medicine, Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2), Member of the Union of Pediatricians of Russia.

Bukreeva E.A. – Physical Therapist, Head of the Physiotherapy and Exercise Therapy Department, V.F. Voino-Yasenetsky Scientific and Practical Center for Specialized Medical Care for Children of the Moscow Healthcare Department.

Bykova O.V. – Doctor of Medical Sciences, Head of the Research Department, Scientific and Practical Center for Children's Psychoneurology of the Moscow Healthcare Department, Professor at the Department of Pediatric Neurology, Physical and Rehabilitation Medicine, Faculty of Continuous Medical Education, Medical Institute of RUDN University, Moscow.

Vinogradov A.V. – Doctor of Medical Sciences, Traumatologist-Orthopedist, Scientific and Practical Center for Children's Psychoneurology of the Moscow Healthcare Department.

Eremeeva S.V. – Dermatovenereologist, Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.

Zhukova O.V. – Doctor of Medical Sciences, Professor, Executive Director of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Central Federal District of the Russian Ministry of Health, Chief Physician of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Head of the Department of Dermatovenereology, Allergology, and Cosmetology, Medical Institute of the Peoples' Friendship University of Russia (RUDN University).

Ivanov A.A. – Pediatrician, Allergist-Immunologist, Russian Children's Clinical Hospital — a branch of the N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health.

Ivanova E.A. – Pediatric Oncologist at Oncology Department No. 1, Junior Researcher at the Research Department, V.F. Voino-Yasenetsky Scientific and Practical Center for Specialized Medical Care for Children of the Moscow Healthcare Department, Member of the Russian Society of Pediatric Oncologists and Hematologists (RSPOH).

Ivanova N.M. – Doctor of Medical Sciences, Professor, Chief Researcher at the V.F. Voino-Yasenetsky Scientific and Practical Center for Specialized Medical Care for Children of the Moscow Healthcare Department, Professor at the L.A. Durnov Department of Pediatric Oncology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Professor at the Department of Pediatric Oncology, M.F. Vladimirsky Moscow Regional Research Clinical Institute; Member of the Russian Society of Pediatric Oncologists and Hematologists (RSPOH).

Kargin V.S. – Candidate of Medical Sciences, Researcher at the Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2).

Klimov Yu.A. – Candidate of Medical Sciences, Deputy Director for Medical Work, Scientific and Practical Center for Children's Psychoneurology of the Moscow Healthcare Department; Head of the Department of Neurology and Neurosurgery, Russian State Social University.

Komarova O.N. – Candidate of Medical Sciences, Gastroenterologist, Nutritionist, Academician Yu.E. Veltiщеv Research and Clinical Institute of Pediatrics and Pediatric Surgery, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health.

Kulichenko T.V. – Doctor of Medical Sciences, Professor of the Russian Academy of Sciences, Head of the National Medical Research Center, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health, World Health Organization Expert, Member of the Union of Pediatricians of Russia.

Materikin A.I. – Candidate of Medical Sciences, Head of the Inpatient Dermatology Department for Children, Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2) of the Ministry of Science and Higher Education of the Russian Federation, Member of the Union of Pediatricians of Russia.

Namazova-Baranova L.S. – Academician of the Russian Academy of Sciences, Professor, Doctor of Medical Sciences, President of the Union of Pediatricians of Russia; Past President of EPA/UNEPSA; Head of the Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2), Head of the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Chief Freelance Specialist in Preventive Pediatrics of the Russian Ministry of Health.

Petrichenko A.V. – Doctor of Medical Sciences, Pediatric Oncologist, Professor at the L.A. Durnov Department of Pediatric Oncology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Professor at the Department of Propaedeutics of Childhood Diseases, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health; Member of the Russian Society of Pediatric Oncologists and Hematologists (RSPOH), Member of the Association of Traumatologists and Orthopedists of Russia (ATOR).

Platonova M.M. – Candidate of Medical Sciences, Researcher at the Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2), Pulmonologist.

Polevichenko E.V. – Professor at the Department of Oncology, Hematology, and Radiology, Institute of Motherhood and Childhood, N.I. Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Doctor of Medical Sciences, Professor, Chief Freelance Pediatric Specialist in Palliative Medical Care of the Russian Ministry of Health.

Potekaev N.N. – Doctor of Medical Sciences, Professor, President of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Russian Ministry of Health, Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Director of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Head of the Department of Skin Diseases and Cosmetology, Faculty of Additional Professional Education, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health.

Porshina O.V. – Candidate of Medical Sciences, Associate Professor, Dermatovenereologist, Deputy Chief Physician for Clinical and Expert Work, Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.

Pytal A.V. – Anesthesiologist-Resuscitator, Russian Children's Clinical Hospital — a branch of the N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health.

Savlaev K.F. – Candidate of Medical Sciences, Pediatric Surgeon at Oncology Department No. 1, Senior Researcher at the Research Department, V.F. Voino-Yasenetsky Scientific and Practical Center for Specialized Medical Care for Children of the Moscow Healthcare Department.

Selimzyanova L.R. – Candidate of Medical Sciences, Head of the Department of Standardization and Study of Evidence-Based Medicine Foundations, Research Institute of Pediatrics and Child Health, Academician B.V. Petrovsky National Research Centre of Surgery (Branch No. 2), Associate Professor at the Department of Pediatrics and Pediatric Rheumatology, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Associate Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatricians of Russia.

Strokova T.V. – MD, PhD, Professor of the RAS, Head of the Department of Pediatric Gastroenterology, Hepatology and Dietotherapy, Federal Research Centre of Nutrition and Biotechnology; Head of the Department of Gastroenterology and Dietology, Institute of Professional Education, Pirogov Russian National Research Medical University.

Sukhanov Yu.V. – MD, PhD, Chief Freelance Specialist in Pediatric Palliative Care of the Moscow Healthcare Department; Head of the First Moscow Children's Hospice Branch, Center for Palliative Care of the Moscow Healthcare Department; Member of the Association of Professional Participants in Hospice Care.

Taran N.N. – MD, PhD, Senior Researcher, Department of Pediatric Gastroenterology, Hepatology and Dietotherapy, Federal Research Centre of Nutrition and Biotechnology; Associate Professor, Department of Gastroenterology and Dietology, Institute of Professional Education, Pirogov Russian National Research Medical University.

Tepaev R.F. – MD, PhD, Head of the Anesthesiology and Intensive Care Service, Bashlyeva Children's City Clinical Hospital; Professor, Department of Pediatrics and Pediatric Rheumatology, Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University).

Titova O.N. – MD, PhD, Pediatrician, Nutritionist, Consultative Department, Federal Research Centre of Nutrition and Biotechnology; Assistant, Department of Gastroenterology and Dietology, Institute of Professional Education, Pirogov Russian National Research Medical University.

Tikhonov S.V. – PhD in Biology, Scientific Secretary, Scientific and Practical Center for Child Psychoneurology of the Moscow Healthcare Department; Associate Professor, Department of Neurology, Physical and Rehabilitation Medicine, Academy of Postgraduate Education, Peoples' Friendship University of Russia (RUDN University), Moscow.

Turti T.V. – MD, PhD, Chief Researcher, Department of Preconceptional, Antenatal and Neonatal Medicine, Research Institute of Pediatrics and Children's Health, Petrovsky National Research Centre of Surgery; Professor, Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Ministry of Health of Russia (Pirogov University); Member of the Union of Pediatricers of Russia.

Shavyrin I.A. – MD, PhD, Trauma Surgeon and Orthopedic Surgeon, Surgical Department No. 1, Leading Researcher, Scientific Department, Voyno-Yasenetsky Scientific and Practical Center of Specialized Medical Care for Children of the Moscow Healthcare Department; Member of the Association of Trauma Surgeons and Orthopedic Surgeons of Russia (ATOR).

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Pediatricians

2. District pediatricians

3. Dietitians

4. Dermatovenerologists

5. Anesthesiologists-intensivists

6. Neurologists

7. General practitioners (family physicians)

8. Pediatric surgeons

9. Palliative care physicians

10. Functional diagnostics physicians

11. Physical and rehabilitation medicine physicians

12. Physiotherapists

13. Residents and postgraduate students

14. Faculty members of pediatric departments at medical universities

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of reliability of evidence (LRE) for prevention, treatment, and rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing the levels of recommendation persuasiveness (LRP) for prevention, diagnostic, treatment, and rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision — at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Russian Ministry of Health No. 120n dated February 20, 2026, "On Approval of the Procedure for Providing Medical Care in the Field of 'Pediatrics'."

2. Order of the Russian Ministry of Health dated November 24, 2021, No. 1094n "On approval of the Procedure for prescribing medicinal products, prescription form templates for medicinal products, the Procedure for issuing these forms, their accounting and storage, prescription form templates containing prescriptions for narcotic drugs or psychotropic substances, the Procedure for their manufacture, distribution, registration, accounting and storage, as well as the Rules for issuing prescription forms, including in the form of electronic documents."

3. Decree of the Government of the Russian Federation No. 3053-r dated December 31, 2018, "On Approval of Lists of Medical Devices Implantable into the Human Body When Providing Medical Care Within the Framework of the State Guarantee Program of Free Medical Care to Citizens and Dispensed by Prescription for Medical Devices Upon Provision of a Set of Social Services."

4. International Statistical Classification of Diseases and Related Health Problems (ICD-10).

5. Order of the Ministry of Health of the Russian Federation No. 434n dated May 14, 2026, "On Approval of the Nomenclature of Positions for Medical and Pharmaceutical Workers."

6. Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'The Fundamentals of Healthcare Legislation in the Russian Federation' Regarding Clinical Practice Guidelines."

7. Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On Approval of the Procedure and Timeframes for the Development and Revision of Clinical Guidelines, Their Template Form, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines".

8. Order of the Russian Ministry of Health No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services."

9. Order of the Ministry of Labor and Social Protection of the Russian Federation No. 585n dated August 27, 2019, "On Classifications and Criteria Used in Medical and Social Assessment of Citizens by Federal State Institutions of Medical and Social Assessment."

10. Order of the Ministry of Health and Social Development of the Russian Federation "On the Procedure for the Use of Medicinal Products in Patients on Vital Indications" No. 494 dated August 9, 2005.

11. Information Letter of the Ministry of Health of Russia on the possibility of procuring a medicinal product by trade name (https://www.rosminzdrav.ru/news/2019/12/18/13043-minzdrav-podgotovil-informatsionnoe-pismo-po-vozmozhnosti-zakupki-lekarstvennogo-preparata-po-torgovomu-naimenovaniyu).

Information on medicinal products: https://grls.rosminzdrav.ru/, https://pharma.eaeunion.org/pharma/registers/26/ru/register

Unified Register of Registered Medicinal Products of the Eurasian Economic Union [Electronic resource]. URL: https://pharma.eaeunion.org/pharma/registers/26/ru/register (accessed: March 22, 2026).

Main regulatory legal acts governing the provision of palliative medical care

1. Federal Law "On Amendments to the Federal Law 'The Fundamentals of Healthcare Legislation in the Russian Federation' Regarding the Provision of Palliative Medical Care" No. 18-FZ dated March 6, 2019.

2. Order of the Ministry of Health of Russia No. 208n, Ministry of Labor of Russia No. 243n dated April 14, 2025, "On Approval of the Regulation on the Organization of Palliative Medical Care, Including the Procedure for Interaction between Medical Organizations, Social Welfare Organizations, and Public Associations, Other Non-Profit Organizations Operating in the Healthcare Sector."

3. Order of the Russian Ministry of Health No. 398n dated July 9, 2025, "On Approval of the List of Medical Devices Intended to Support Human Body Organs and Systems, Provided to a Patient in the Provision of Palliative Medical Care for Home Use".

4. Order of the Russian Ministry of Health No. 505n dated July 10, 2019, "On approval of the Procedure for the transfer by a medical organization to a patient (their legal representative) of medical devices intended to maintain the functions of human organs and body systems for home use in the provision of palliative medical care."

Appendix A3.1 Mechanism of pressure ulcer formation [70]

Appendix A3.2 Signs and symptoms of chronic wound infection

All of the symptoms listed below are indications for hospitalization of an outpatient for diagnostic examinations and selection of drug therapy. If the patient is already hospitalized, the previously prescribed treatment requires correction or additional prescriptions.

1. Delayed healing, defined as a lack of progress in wound closure and no reduction in wound size. If standard care is provided and there are no signs of improvement within 2 weeks, infection should be suspected.

2. Change in the color of granulation tissue (edematous granulation tissue or pale, dark color), as opposed to the red, fleshy color of healthy granulation tissue.

3. Friable granulation tissue that bleeds spontaneously or upon minor trauma.

4. Formation of pockets at the base of the wound or depressions lacking granulation tissue.

5. Unpleasant odor, usually caused by gram-negative organisms and typically associated with anaerobic organisms.

6. Wound breakdown, characterized by increased size, loss of epithelium, exposure of bone tissue, and loose granulation tissue, resulting from abnormal collagen formation caused by high bioburden.

7. Increased pain levels, even in the absence of any noticeable signs of inflammation, may indicate wound infection [113].

Appendix A3.3 FAO/WHO/UNU equations for basal energy expenditure in children

Appendix A3.4 Calculation of energy requirements in children across different age groups using the Harris-Benedict formula

Notes: BER – basal energy requirement; REE – resting energy expenditure (basal metabolic rate).

Appendix A3.5 Calculation of basal energy expenditure using the Schofield formula

Notes: Cit. Schofield WN, where W is body mass; H is height.

Appendix A3.6 Coefficients for calculating energy requirements in sick children of various profiles

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

1. Pressure ulcers are localized injuries to the skin and/or underlying tissue, usually occurring over a bony prominence as a result of prolonged pressure or pressure combined with shear or friction. The most common sites for pressure ulcer development are the skin covering the sacrum, coccyx, heels, and hips, although other areas may be affected: knees, ankles, back of the shoulders, or occiput, and in newborns, areas adjacent to masks, nasal cannulae, etc.

2. The most effective method for managing pressure ulcers is prevention. Modern pressure ulcer prevention encompasses a range of approaches and must take into account the patient's condition, as well as the resources and qualifications of the medical staff.

3. Comprehensive treatment of pressure ulcers depends on their stage and includes both pharmacotherapy (local and systemic), surgical intervention, nutritional support (nutrition), physical therapy, and preventive measures. The type of treatment is determined by the physician.

4. The main risk factors for the development of pressure ulcers are: continuous pressure, shear forces, friction, exposure of the skin to urine, feces / other moist substances, malnutrition, inability to periodically change body position, and medical equipment attached to the patient's body (e.g., masks, pulse oximeters, etc.), overweight or underweight, and comorbid conditions (diabetes mellitus, neurological disorders, etc.).

5. Monitoring of the patient by medical personnel / relatives is recommended in the form of regular hygienic care, maintaining cleanliness and moderate humidity; monitoring fluid intake and nutritional adequacy; preventing incorrect positioning and "sliding" in bed; eliminating contributing factors (itching, irritation, psychological discomfort, insomnia, etc.).

6. Education of patients capable of self-care or their legal representatives.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Braden QD Scale

Russian title: Braden Scale.

Original title: Braden QD scale.

Source (official developers' website): 15, 16, 114, 115, 116, 117, 118.

Type (underline): rating scale.

Purpose: the scale is designed to assess the risk of pressure ulcer development in children and newborns, taking into account the anatomical and physiological characteristics of childhood.

Content:

*Any diagnostic or therapeutic equipment attached to the skin or passing through the skin or mucous membrane must be taken into account when assessing the risk in a patient.

Key:

Patients are assessed on each of the 7 scale items, then the scores are summed up. A total score ≥ 13 identifies a patient at risk for hospital-acquired pressure ulcers.

Notes:

The patient's risk is assessed within 24 hours of hospital admission and re-assessed when the patient's condition changes. Preventive and therapeutic measures should be directed at those items for which the patient received ≥ 1, as they indicate the presence of a clinically significant risk of pressure ulcer development.