When treating children with lymphedema, health care providers must ensure they apply bandages with appropriate delicacy and care. This author provides a practical guide to bandaging for children and applying compression maintenance garments.
Primary lymphedema is an inherited disease in which predisposing genetic factors cause defects in lymph transportation, which may result from missing lymph nodes, missing vessels, or abnormal vasculature that prevents sufficient lymphatic movement. In the United States, primary lymphedema affects approximately 0.6% of live births and in which there is a congenital defect of the lymph-transporting system. It can be present at birth, develop at the onset of puberty, or present in adulthood.1 Those affected may have swelling in one or more limbs and various parts of the body.
In 1998, during my training as a certified lymphedema therapist (CLT) we learned about three classifications for primary lymphedema: congenital, praecox (onset before age 35) and tarda (onset after age 35).2 To further confuse the issue, Weissleder and Schuchhardt identified hereditary lymphedema as Nonne-Milroy-Meige syndrome subdivided into two types: Type I Nonne-Milroy hereditary congenital elephantiasis manifesting at birth, and Type II Meige-non-congenital familial lymphedema praecox manifesting during puberty.3
Fast forward to 2020. With today’s advanced imaging technologies and genetic testing, there are no less than 40 genetic syndromes associated with primary lymphatic anomalies. A recent Journal of Medical Genetics article references the updated St. George’s classification algorithm of primary lymphatic anomalies that “brings the classification of primary lymphatic disorders in line with the International Society for the Study of Vascular Anomalies 2018 classification for vascular anomalies. The St. George’s algorithm considers combined vascular malformations and primary lymphatic anomalies, dividing the types of primary lymphatic anomalies into lymphatic malformations and primary lymphedema. It further divides the primary lymphedema into syndromic, generalized lymphatic dysplasia with internal/systemic involvement, congenital-onset lymphedema and late-onset lymphedema.”4
Tailoring Lymphedema Treatment to Pediatric Patients
Complete decongestive therapy (CDT) is the standard of care for treating lymphedema; however, the pediatric population requires a different approach from that of treating adults. The treatment components are similar to that for treating adults (manual lymphatic drainage, compression bandaging, skin care, exercise) but contrary to the medieval thinking that children are “little adults,” we must carefully consider the approach in treating pediatric patients with lymphedema especially with compression bandaging. Medical professionals who work with infants and small children daily require a particular set of tools, toys, and tricks of the trade.
Perhaps the skills I developed in my previous life as an animal medical technologist (translated: animal nurse), such as patience, distraction techniques, and owner education, prepared me to work with pediatric patients. A slower pace is needed with pediatric patients as many require a “warming up” period to a new person or environment. The initial therapy evaluation includes a medical history, volumetric measurements, assessment of mobility and function and skin and/or wound assessment. Following this, step one in treating a child with lymphedema is educating the primary caregiver. Caregivers take on the responsibilities of the lymphedema management so it is important to establish a care plan that is compatible with the child and caregiver, modifying the CDT program as needed.
Clinical skills and experience for addressing the physical, psychosocial, and functional needs of the child and family are invaluable.5 When working with adult patients, a therapist can lay out a plan of care and have immediate verbalized agreement with the patient. However, when working with children, it helps if the therapist is in touch with their “inner child” and is adept at engaging the tiny patients who come with no preconceived notion of what therapy is supposed to be. What may start as Plan A for therapy may turn into Plan B, C or D. Therefore, flexibility, variety and thinking outside the box are required. Play areas can be set up to allow the child to engage in play while basic manual lymphatic drainage (MLD) is performed or while sitting in the lap of a parent. Older children can be taught self-care, for example applying their own moisturizer, simple self-MLD techniques or deep breathing techniques.
One of my 2-year-old patients learned deep breathing by reciting the lines from “The Three Little Pigs,” where the wolf would “huff and puff and blow the house down.” Blowing-activated toys like a pinwheel or blowing bubbles can assist a child in learning how to engage the diaphragm.
Lymphedema bandaging for children presents with unique challenges. Bandaging is an art unto itself and demands quality time for instructional methods that help parents become confident in their bandaging skills. It is a team approach of therapist, parent, and child. It is essential that parents practice bandaging skills with sessions that may follow this order: practicing on the therapist, practicing on themselves, practicing on a child’s older sibling, and eventually practicing on the patient.6 The rationale and techniques of compression bandaging for infants and children are the same as those for any other age and include monitoring for signs of excessive pressure, skin color changes and capillary refill. Other signs to watch for are signs of discomfort like crying or fussiness. Assess for other skin irritations like blisters or petechiae (small red dots that appear from breakage of small blood capillaries) that result from too much pressure. The risk of cellulitis, fungal infections and skin injury is increased with these patients therefore meticulous skin care is extremely important.
Practical Tips on Bandaging Materials and Technique
Bandaging materials for pediatric patients consist of gentler fabrics to avoid skin irritation, skin tears or trauma. Fabrics may include a terry cloth stockinette, soft roll gauze, and cotton or cotton-like padding or lambswool. A multilayered soft roll gauze can be used alone as a compression wrap for smaller hands and feet. Placing a tubular stockinette covering over it will help to prevent small fingers from pulling, picking, and otherwise undoing all the hard work of the therapist or caregiver.
Typically, stockinette is the first layer when using a multicomponent compression wrap. Most stockinette brands come in a large variety of widths ranging from 1.4 cm up to 12 cm. One pediatric CLT therapist I know wraps over the child’s tights instead of using stockinette. Other bandaging products like soft foam or cotton padding rolls come in smaller sizes, and if not small enough, can be cut to the needed width or length. For small legs and arms, I have had good results using padded stockinette such as tg soft (Lohmann & Rauscher) and a 4 cm x 5 cm short stretch bandage. Alternatively, comfortable compression can be created by using a thinner stockinette with lots of padding and fewer layers of short stretch bandaging covered with another stockinette on top. Again, always monitor for any skin irritation.
Creating sufficient gradient compression by layering is important to create a high working pressure for maximal edema reduction, but layering should not prevent any restriction in movement. For infants and children, the occupation of play is developmentally important and compression bandaging should not restrict the ability to play or move. A caregiver may opt to perform bandaging prior to bedtime if maintaining a daytime wrap becomes problematic, or if a daytime “bandage break” is needed.
Therapists should use extra caution when applying toe wraps on infants or small children to prevent splay-toe deformity or prevent restriction in the ability to walk or crawl. A folded 1 cm or 4 cm gauze roll may work nicely on small toes and feet. A taping method using a gentler adhesive formula on the feet and toes is effective alone or in conjunction with compression bandaging or garments. I use the kinesiotape brand called Kinesio Tex Gold (Kinesio) but there may be others that work as well for sensitive skin types. If tape sensitivity is an issue, skin prep using a thin layer of milk of magnesia helps prevent irritation. Always do a 24-hour test strip prior to the first application.
A 3-year-old patient of mine whose toes and feet responded well to kinesiotaping loved the blue tape that we called “Thomas the Tank Engine Blue.” We also employed Thomas the Tank Engine videos during his session as a distraction. Children with venous anomalies such as Klippel-Trénaunay-Weber syndrome may benefit from silicone wound care products to protect fragile and sensitive skin under bandaging. Appropriate wound care products for sensitive skin should be selected for patients prone to skin breakdown.
Fitting Compression Maintenance Garments
After the hurdle of MLD and bandaging comes measurements for maintenance garments. Experienced certified fitters are worth their weight in gold and are trained to measure custom garments for any size and shape. Most compression garment companies that specialize in custom compression garments for lymphedema offer a variety of colors. For the pediatric patient, there are options to customize garments further by adding a sewn-in patch of cartoon characters, animals, etc.
Compression sleeves or stockings are worn daytime only due to their high resting pressure. Custom garment measurements should be taken every 4–6 months as the elastic garments lose compression or a growth spurt demands a larger size. Most children can tolerate a compression garment by the age of 2 or 3 years old. Compression class I (18–21 mmHg) is usually adequate and easiest to don. As children grow older and bigger, a class II (25–32mmHg) is appropriate. Prior to his therapy with me, a 4-year-old patient was prescribed 30–40mmHg custom stockings and as a result, developed painful ingrown toenails. That patient is now 11 years old and has found a good combination of an open-toe knee-high with toe caps that he switches out with his Velcro wraps from day to day.
There was a time that several garment manufacturers offered special pediatric programs allowing free or substantially discounted pricing on daytime maintenance garments or nighttime garments. It is worth the effort to seek out the manufacturers’ representatives for additional assistance and information. Lohmann & Rauscher (formerly Solaris), the manufacturer of the TributeNight™ garment, offers the “Early Impressions Program” that provides children garments at no cost or reduced cost pricing depending on the child’s age. Having a versatile garment such as a Velcro strap compression like the FarrowWrap™ Lite can accommodate a child’s growth rate for a longer period and be easily removed for skin care and bathing and may be worn day or night.
While experience and technique help in treating infants and children, the therapist must always remember that caregiver education on diagnosis and prognosis along with psychosocial and emotional support and resources will support successful therapy treatment and carryover.
Denise M. Baylor, OTR, LMT, CLT-LANA, CSWS, is a lymphedema and wound care certified therapist with 22 years of clinical experience in lymphedema therapy and wound care management in Houston.
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