Neonatal Case Studies Using Active Leptospermum Honey

Wound healing properties of flavonoids: A systematic review highlighting the mechanisms of action

BACKGROUND

Flavonoids are a class of compounds with a wide variety of biological functions, being an important source of new products with pharmaceutical potential, including treatment of skin wounds.

PURPOSE

This review aimed to summarize and evaluate the evidence in the literature in respect of the healing properties of flavonoids on skin wounds in animal models.

STUDY DESIGN

This is a systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

METHODS

This was carried out through a specialized search of four databases: PubMed, Scopus, Web of Science and Embase. The following keyword combinations were used: "flavonoidal" OR "flavonoid" OR "flavonoidic" OR "flavonoids" AND "wound healing" as well as MeSH terms, Emtree terms and free-text words.

RESULTS

Fifty-five (55) articles met the established inclusion and exclusion criteria. Flavonoids presented effects in respect of the inflammatory process, angiogenesis, re-epithelialization and oxidative stress. They were shown to be able to act on macrophages, fibroblasts and endothelial cells by mediating the release and expression of TGF-β1, VEGF, Ang, Tie, Smad 2 and 3, and IL-10. Moreover, they were able to reduce the release of inflammatory cytokines, NFκB, ROS and the M1 phenotype. Flavonoids acted by positively regulating MMPs 2, 8, 9 and 13, and the Ras/Raf/MEK/ERK, PI3K/Akt and NO pathways.

CONCLUSION

Flavonoids are useful tools in the development of therapies to treat skin lesions, and our review provides a scientific basis for future basic and translational research.

Recommendations for Management of Noncytotoxic Vesicant Extravasations

To prepare clinicians to treat extravasation of noncytotoxic vesicants with antidotes and thermal compresses, a literature review was performed to identify noncytotoxic vesicants and to create evidence and consensus-based recommendations. The stage of injury and vesicant's mechanism of tissue injury dictate treatment. For a vasopressor extravasation, warm compresses and administration of a vasodilator are recommended. For osmolarity, pH, absorption refractory, and cytotoxic concentration-dependent vesicants, warm compresses and administration of hyaluronidase are recommended. Compared with potentially catastrophic costs of undertreatment, the cost of overtreatment is minimal.

Medical-Grade Honey for the Treatment of Extravasation-Induced Injuries in Preterm Neonates: A Case Series

INTRODUCTION

Preterm neonates often depend on peripheral intravenous administration of nutrition and medication. Since their skin is not fully developed and very vulnerable, extravasation injury is a risk. Medical-grade honey (MGH) possesses antimicrobial activity and stimulates wound healing; although its use in neonatal patients is limited.

CLINICAL FINDINGS

We present a case series of 7 preterm neonates (28-36 weeks of gestation) with extravasation injuries secondary to peripheral intravenous administration of total parental nutrition and medication.

PRIMARY DIAGNOSIS

Extravasation injury following the unintentional leakage of total parenteral nutrition, and medication into the surrounding tissue. Signs of extravasation include local pain, erythema, burning, pruritus, and/or swelling.

INTERVENTIONS

All extravasation injuries were treated with daily cleaning and application of MGH. Some of the cases needed additional surgical intervention or assisted debridement.

OUTCOMES

After treatment, all extravasation injury wounds presented with granulation tissue formation progressed to normal epithelialization and closed in 7 to 67 days (median: 32 days). Upon initial application, peripheral edema and inflammation decreased. When present, necrotic tissue was effectively debrided, slough was removed, and no signs of infection were detected, irrespective of initial wound presentations. Cicatrization was minimal, and the full range of motion was preserved in all cases.

PRACTICE RECOMMENDATIONS

Continuous and thorough assessment of peripheral intravenous line placement for malposition, leaking, and signs of extravasation is needed for fast discovery and prevention of further damage.

CONCLUSION

Medical-grade honey possesses antimicrobial, anti-inflammatory, and antioxidative activity, enhancing wound healing. Medical-grade honey was safe and effective for treating extravasation-induced injuries, independent of location and severity. We recommend MGH for treating extravasation wounds and consideration for other types of wounds.

Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review

OBJECTIVE

Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously.

METHOD

Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included 'wound care', 'wound management', 'paediatrics', 'children', 'skin substitutes', and 'grafts'. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: 'Apligraf', 'dermagraft', 'Manuka honey', 'antibiotic', 'timolol', and 'negative pressure wound therapy' (NPWT).

RESULTS

Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount.

CONCLUSION

Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.

Treating severe wounds in pediatrics with medical grade honey: A case series

Medical grade honey (MGH) has antimicrobial and pro-healing properties. We here demonstrate that MGH is an easily applicable, safe, and cost-effective approach for severe wounds. The use of MGH should more often be considered to treat all kinds of pediatric wounds.

Medical grade honey for the treatment of paediatric abdominal wounds: a case series

Objective:

Children are at high risk of injuries and wounds. The application of medical grade honey is a promising approach to improving the healing of wounds of various origin and severity. However, the use of medical grade honey in young paediatric patients remains limited. The aim of this study is to show the safety, efficacy and usefulness of medical grade honey in abdominal wounds, of different causes, in paediatric patients.

Method:

This was a prospective, observational case series evaluating five young infants with abdominal wounds at the General Hospital in Thessaloniki. All wounds were treated in the same manner with daily medical grade honey applied to the wound area and closely monitored.

Results:

All treated wounds rapidly presented granulation tissue formation and underwent re-epithelialisation. Peripheral oedema and inflammation decreased upon initial application. Necrotic tissue was effectively debrided when present. Slough was removed and no signs of infection were detected, irrespective of initial wound presentations. Scar formation was minimal and the full range of motion was preserved in all cases.

Conclusion:

Based on this case study, medical grade honey is safe and effective in treating different abdominal wounds, including infected or dehisced wounds as well as burns. The easy application and broad applicability make medical grade honey recommendable as a first-line treatment in paediatric patients.

Treatment of extravasation injuries in infants and young children: a scoping review and survey

BACKGROUND

Extravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines, but there is no consensus on the best treatment approaches.

OBJECTIVES

To identify which treatments may be best for treating extravasation injuries in infants and young children.

DESIGN

Scoping review and survey of practice.

POPULATION

Children aged < 18 years with extravasation injuries and NHS staff who treat children with extravasation injuries.

INTERVENTIONS

Any treatment for extravasation injury.

MAIN OUTCOME MEASURES

Wound healing time, infection, pain, scarring, functional impairment, requirement for surgery.

DATA SOURCES

Twelve database searches were carried out in February 2017 without date restrictions, including MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus and EMBASE (Excerpta Medica dataBASE).

METHODS

Scoping review - studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were grouped by design, and then by intervention, with details summarised narratively and in tables. The survey questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. Summary results were presented narratively and in tables and figures.

RESULTS

The evidence identified in the scoping review mostly comprised small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase (without flush-out), artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in age, types of infusate, injury severity, location of injury and the time gaps between injury identification and subsequent treatment. Some of the better evidence related to studies of flush-out techniques. The NHS survey yielded 63 responses from hospital units across the UK. Results indicated that, although most units had a written protocol or guideline for treating extravasation injuries, only one-third of documents included a staging system for grading injury severity. In neonatal units, parenteral nutrition caused most extravasation injuries. In principal oncology/haematology units, most injuries were due to vesicant chemotherapies. The most frequently used interventions were elevation of the affected area and analgesics. Warm or cold compresses were rarely used. Saline flush-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design, though opinions varied greatly by setting.

LIMITATIONS

Paucity of good-quality studies.

CONCLUSIONS

There is uncertainty about which treatments are most promising, particularly with respect to treating earlier-stage injuries. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials.

FUTURE WORK

Conventional randomised trials may be difficult to perform, although a randomised registry trial may be an appropriate alternative.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Novel Use of Active Leptospermum Honey for Ringed Fixator Pin Site Care in Diabetic Charcot Deformity Patients

INTRODUCTION

Open reduction with external fixation (OREF) utilizing fine wire ringed fixators for correction of Charcot deformity has gained popularity over the past decade. Pin site infections are a well-documented complication of external fixation as well as a driver of escalating health care costs. We aimed to demonstrate the safety and efficacy of a novel method of pin site care utilizing active Leptospermum honey-impregnated dressings (MediHoney) in diabetic patients undergoing deformity correction with OREF.

METHODS

Twenty-one diabetic patients with Charcot deformities of the lower extremity were prospectively enrolled and followed for pin site complications following OREF for deformity correction. Active Leptospermum honey dressings were applied at metal-cutaneous interfaces at the end of the OREF procedure and replaced weekly for a total of 8 weeks. Patients were monitored for pin site infections from the time of surgery until external fixator removal. Sixteen consecutive patients receiving standard OREF for Charcot deformities were evaluated retrospectively to serve as a control group.

RESULTS

Of the 21 enrolled patients, 19 underwent OREF and followed up throughout the study period. Treated patients had a mean age of 58.5 years and mean body mass index measuring 33.3 kg/m² as documented prior to surgery. The 15 patients with hemoglobin A1c labs drawn in the 3 months preceding surgery averaged 7.5. Fixators were removed at an average of 12.1 weeks after adequate bony healing. Of the 244 pin sites in 19 patients, 3 pin sites (1.2% of pins) in 2 patients (10.5% of patients) showed evidence of superficial infection. All infections resolved with oral antibiotics. Infection rates were significantly reduced when compared to the standard care control group.

CONCLUSIONS

Pilot data in a prospectively collected case series demonstrate safety and efficacy of active Leptospermum honey-impregnated dressings when used for fine wire ringed fixator pin site care in diabetic Charcot deformity patients. Further investigation in the form of a prospective randomized controlled study is warranted to demonstrate the potential value of this novel intervention.

LEVELS OF EVIDENCE

Level IV.

[The care of skin lesions caused by extravasation of intravenous fluids in peripheral venous perfusion]

INTRODUCTION

Infiltration and extravasation account for 23-78 % of the complications stemming from peripheral venous perfusions in neonatal intensive care units. Their consequences, sometimes dramatic, can be pain, infections, or even loss of skin, which can lead to nerve and/or muscle damage, particularly severe for preterm neonates. Today there are no recommendations on the care of these lesions, which can lead to an erroneous choice or to a delay in the possible treatments.

OBJECTIVE

This review of the literature aims to explore and propose elements of therapeutic care collected in the scientific literature. It focuses on skin lesions due to extravasation of peripheral venous perfusions in neonatal intensive care units.

METHODS

The PubMed database and the publishers' platform ScienceDirect were used. The bibliographies of the selected articles were also run. All types of studies examining one or several treatments for the care of postextravasation skin lesions in neonatal intensive care units were included in the search, without any limit on the date, except for case reports. To estimate the quality of the studies, the tool proposed by the French National Authority for Health, which classifies the various types of studies according to their proof level, was used.

RESULTS/DISCUSSION

Thirteen publications were analyzed, including four case series, five retrospective studies, and four interventional studies. The vast majority of these studies have been published since 2005. No comparative, controlled, and randomized trials appear in the literature. Chronologically, we observed a growing interest in the premature infant population, in parallel with the increasing number of publications. Among the significant number of treatments proposed, five main categories were identified: topical treatment, surgery, the Gault method, no specific treatment, and others. All the skin lesions of the babies studied healed, without important aftereffects. These publications also show that most of the time a combination of different types of treatment is used depending on the lesions' progress and doctor's assessment. Few differences are made between term neonates and premature neonates in the choice of treatment. All these types of care can be applied to both populations. In spite of the lack of consensus on the care to be adopted, all the authors emphasize the important role of prevention according to the official regulations.

CONCLUSION

The total absence of studies with a sufficient level of proof does not allow, at this time, the elaboration of guidelines for the care of these lesions. However, the proposals made in the literature seem promising. Therefore, it would be wise to conduct randomized trials on relatively large samples to compare these various types of treatment.

Honey and Wound Healing: An Update

For centuries, honey has been utilized for wound healing purposes. In recent times, this specific topic has become a field of interest, possibly due to the advent of antibiotic resistance in microbial pathogens. With constant technological advancement, the information regarding honey's mechanisms of action on wound healing has accumulated at a rapid pace. Similarly, clinical studies comparing honey with traditional wound care therapies are steadily emerging. As a follow-up to a previous review published in the journal in 2011, the current review article outlines publications regarding honey and wound healing that have been published between June 2010 and August 2016. Here we describe the most recent evidence regarding multiple types of honey and their mechanisms of action as antimicrobial agents, immunologic modulators, and physiologic mediators. In addition, outcomes of clinical studies involving a multitude of cutaneous wounds are also examined.

Leptospermum Honey for Wound Care in an Extremely Premature Infant

BACKGROUND/INTRODUCTION TO CASE

Neonatal wound care is challenging due to the fragility and vulnerable skin structure. Neonates are often left susceptible to the forces of their environment, leaving them open to infection when skin injury occurs. Leptospermum honey has been used successfully in adult patients, with evidence lacking in the neonatal population. This case demonstrates the management of a difficult-to-heal wound in a 23-week gestation infant.

PURPOSE

Selecting the proper treatment and products for wound healing is challenging, with little evidence-based research available for the treatment of neonatal wounds. Leptospermum honey and other adult-driven dressings have been used for neonatal wound care as well as other adult-driven dressings. This case demonstrates the benefits of Leptospermum honey as an option for neonatal wounds.

CASE FINDINGS/RESULTS

This case presents the treatment and healing of an extensive wound of a 23-week gestation neonate using a hydrogel product initially and then transitioning to a Leptospermum honey dressing due to suboptimal healing. Results of this treatment included quick healing time, little to no scarring, and no loss of movement or function to the affected extremities.

IMPLICATIONS FOR PRACTICE

The incorporation of Leptospermum honey for wound care has the potential to promote faster wound healing, with less scarring in the neonatal population.

IMPLICATIONS FOR RESEARCH

Adult wound care principles have been applied in the face of a weak evidence base relating to neonatal-specific cases. There is a need for continued research related to moist wound healing in the neonatal population, with resulting product and practice recommendations.