Predicting Prevention: A Retrospective Review of High-Risk Children Placed on Crib Mattresses Designed to Support Skin Integrity

Charleen Singh, MSN/Ed, RN, NFP-BC, CWOCN; and Erica Thibault MS, PhD (c), RN, CNS, APN, CWON


Identifying children at risk for skin breakdown has improved as the organization has engaged in national efforts to improve awareness and promote education among all staff. Children are identified either at admission or early in the acute illness phase. As the organization has developed policies aimed at prevention—which addressed support surfaces—there remained a gap in resources. Until recently, the availability of pressure redistribution mattresses for cribs was limited and cost-prohibitive.
With the availability of a pressure redistribution mattress that is custombuilt for existing crib frames, the children’s organization was able to purchase mattresses for children at risk for pressure ulcers. The pressure redistribution mattresses designed for cribs that are used in the intensive care unit fills the void which has existed in pediatric children’s hospitals with respect to children who require a crib and not a bed or an isolette.


A retrospective review of charts was done of children who were identified to be in the crib with the pressure redistribution mattress. All children who were identified to be on the mattress during the six-week period were included in the chart review. The chart was reviewed for skin integrity upon admission, prior to discharge, and any documentation of skin breakdown related to resting surface pressure. Variables measured were age, weight, height, length of stay, days on mattress, and hours of intubation as well as pH and temperature while on mattress. Albumin was recorded as variable to factor in as a reflection of nutrition status.


During the six-week time frame, a total of 22 children were in a crib with a pressure redistribution mattress. All children’s charts were included in the chart review. The median age of the cohort was less than one year of age. Fifteen of the children were less than one year of age and had the longest intubation times. The children at highest risk had Braden scores of 9 and were on Extracorporeal Membrane Oxygenation (ECMO). There were no members of the cohort who were identified with skin breakdown per documentation in the nurses’ notes or the providers’ discharge exam. In the quarter prior to the mattress trial, there were nine incidences of deep tissue injuries on three different children. The children who had developed pressure ulcers prior to the mattress switch were similar in demographics to the children who were on the new mattresses.

Demographic Characteristics of Participants

Variable N Percent
Male 10 45.5%
Female 12 54.5%
Caucasian 9 41.0%
Hispanic 11 50.0%
Other 2 09.0%
Primary Diagnosis
Cardiac 6 27.3%
ECMO 2 09.1%
Sepsis 3 13.6%
ENT 2 09.1%
Respiratory 3 13.6%
Neurology 2 09.1%
Post-Surgical 4 18.2%

Treatment Characteristics

Variable N % Mean
Yes 17 77.3%
No 5 22.7%
Hours 2425 151
Paralytics 16 72.7%
Sedation 19 86.4%
Waffle Cushion/Z-flo 7 31.8%

Mean and Standard Deviations of Variables

Variable Mean SD
Age in Months 17.7 22.0
Length of Stay Days 36.3 50.63
Days on Mattress 18.8 15.7
Hct 10.2 3.8
Hgb 30.5 11.3
Arterial pH 7.30 0.12
CRP 1.5 2.3
Albumin 3.8 0.68
Temperature 36.6 0.25


Despite the limited sample size, the chart review revealed children who were placed on the mattress were at high risk for pressure ulcers. The small sample size encompassed children at the highest risk for skin breakdown related to hemodynamic instability, immobility, and nutrition during ECMO. There were two children who were on ECMO and on the new mattress who maintained skin integrity. In the previous quarter, children of similar size with lesser acuity developed multiple areas of deep tissue injury. The use of a pressure redistribution mattress in high-risk children is another reasonable nursing intervention to maintain skin integrity. A retrospective study with a larger sample size would support evidence-based practice.
There was a 100 percent reduction in incidence of pressure ulcers when compared to a similar cohort group prior to the mattress conversion.

About the Authors

Charleen Singh practices in both the acute care and the community setting working with children at Shriners Hospital for Children and adults in skilled nursing facilities after being the CWOCN at Stanford Children’s for the past 8 years. Charleen cofounded the San Jose State Wound Ostomy Program which is the only accredited program in California and enjoys teaching nurses the art and science of Wound Ostomy care.

Erica Thibault is the Clinical Manager of Sizewise, is a registered nurse, a Certified Wound Ostomy Nurse (CWON) and a Nursing Research PhD candidate specializing in pressure ulcer prevention. She is a member of the Wound, Ostomy and Continence Nurses Society, the World Council of Enterostomal Therapists and the Sigma Tau International Honor Society for Nurses.