Pediatric Series

Moisture Control

Why Everyday Moisture Can Be So Detrimental to Your Littlest Clients

Moisture ControlAmong the things necessary for life — plant or animal — are air to breathe, food or nutrients to sustain us and enable growth, and water, which enables so many internal processes to carry on.

Deprive people of adequate amounts of fluid for even short amounts of time, and the detrimental effects start piling up quickly. According to the Mayo Clinic, mild dehydration can lead to headache, dizziness or light-headedness, dry skin, decreased urine output and sleepiness or, in children, a decrease in activity.

At the same time, too much fluid can cause other problems, particularly for people who use wheelchairs, because liquids can become trapped in seating & mobility equipment, or on the clients themselves. The situation can become even more challenging among clients who have incontinence issues, need assistance with toileting and hygiene activities, or have difficulty telling caregivers when they need help or are uncomfortable.

And then there are clients who are simply more prone to have “moisture accidents.” For example, picture a pre-school classroom full of kids running and wheeling around. Even if your wheelchair-using client has good saliva control, has great toileting skills and speaks up when he needs to go to the bathroom, that won’t prevent him from getting splashed while playing at the water table, or spilling the occasional cup of apple juice during snack time.

Not to mention the fact that his classmates will spill their apple juice while hanging onto their buddy’s wheelchair.

Moisture & Skin Health

Moisture and healthy skin go hand in hand, but Jean Sayre, MSOT, COTA/L, ATP, CEAC, says there’s a fine balance to that relationship.

“Moisture can either be a friend or a foe,” she explains. “On the one hand, moisture — in the form of hydration — assists in maintaining the elasticity of the skin. On the other hand, too much exterior moisture can create inflammation and irritations, which may cause skin infections via bacteria or fungus. Skin folds are areas that are highly susceptible to the accumulation of perspiration moisture. This moisture will also occur in areas where orthotics are utilized.”

So if the right amounts of moisture are paramount to helping the skin to stay elastic, healthy and less prone to breakdown, what’s the flip side? Why is uncontrolled or lingering moisture such a danger to wheelchair users?

“Moisture alters the resistance of the epidermis to external forces by softening the skin’s surface and reducing the tensile strength,” Sayre says. “For seated children using wheelchairs, urine, feces, perspiration and/or wound drainage may soft en the skin, making it more susceptible to pressure, shear and friction and ultimately to breakdown resulting in pressure ulcers.”

Moisture & Wheelchair Component Health

Wheelchairs, seating systems and positioning components are built to work in environments where moisture exists, of course, but too much moisture can also endanger their ability to function well.

“Moisture is also taken into consideration when in the design process and development of seating systems and power wheelchairs,” Sayre says. “The strategic placement of the electronic control module and other power supplies should be considered if there is the issue of incontinence and may create an unsafe situation for the client if placed underneath the seat pan. Manufacturers perform liquids testing to ensure all flows safely away from susceptible areas. However, parents and clinicians should monitor a child’s situation to properly contain any issues with liquids.”

Even naturally occurring moisture, including rain and snow, can potentially cause problems.

“Environments that possess high humidity create moisture that can also alter the drive controls and motors, causing rusting conditions for wheelchairs and seating systems,” Sayre points out. “This is another reason that aggressive testing is completed: to ensure that all of the components will pass certain restrictive testing criteria for the safety of the client and integrity of the material.”

Any damage to seating & mobility equipment — or while equipment is being cleaned — can cause activity “down” times for the equipment user and could potentially limit or lower that user’s independence level.

“Moisture can impact functionality if the person should acquire a pressure ulcer, ”Sayre says. “Depending upon the staging, it could impact the occupations of the child and caregiver, such as transfers, eating, bladder/bowel, respiratory, positioning, sleeping, playing, school, and so on. Also, if the person doesn’t have the availability of having a second cushion, then the person’s functionality will be compromised if they need to transfer to bed while the cushion and/or seating system is being laundered.”

Planning for the Inevitable

Especially with younger children, needing to deal with a certain amount of moisture seems inevitable, whether because of toileting accidents, arts & craft s projects at school, spills during snacks and meals, or outdoor activities. In anticipation of that, many seating manufacturers offer cushions and backrests, for example, in fabrics that are waterproof or water resistant.

That sounds like a great idea, but as with any complex seating & mobility system, Sayre says each situation should be reviewed in its own right.

“Th e choice of the material is very important for the seating system, but also the choice of clothing is also very influential,” she says.

“Many people feel that obtaining a cushion that is closed-cell foam and with a ‘waterproof’ or fluid-resistant material is helpful. This is only helpful in protecting the cushion. Th e fact is, the body is expelling toxins in urine and feces which, if they remain near the body and are not wicked away, increase the chance of skin inflammation, which may turn into an infection, resulting in an open wound.”

Sayre suggests that if the client has challenges with managing perspiration, “It is best to use a cushion and covers that are composed of breathable materials to permit the air flow to wick away the moisture and promote the breathability factor. I know that insurance doesn’t pay for two cushions, but it would be best to have a second cushion — just in case one is soiled, the other could be laundered.”

In addition, she says caregivers need to be vigilant with clients who use diapers.

“The little ones that have diapers or are being bladder/bowel trained need to be changed immediately,” she says. “The back, headrest, and positioning accessories of the seating system also need to have a breathable material to assist with moisture and temperature issues. This may include the legrests.”

Moisture-Control Strategies

Developing a successful moisture-control strategy that maximizes the child’s independence and activity while minimizing down time and skin breakdown risk will likely require the ATP or clinician to educate caregivers and parents.

Sayre suggests working with the adults in the child’s life so they understand where the most susceptible areas of moisture are likely to be for children:

  • Skin folds
  • Axillary (armpit) areas
  • Between the finger and toes
  • Neck creases
  • Under breasts
  • Buttocks and the perineal area
  • Abdomen
  • Any joint area, especially if there is evidence of obesity, contractures or spasticity

“Educating them on what materials to use for the seating systems and bed system, the temperature of the environments, and that the child should have breathable, stretch material for cushions and cotton fabric for clothing and such is very important,” Sayre says. “Educating caregivers that the child should be changed immediately if there is evidence of any type of moisture accident, and that the cushion should also be checked for cleanliness and dryness, is vital as well.”

Seating & mobility professionals can also reduce the impact of moisture by sharing advice on how to best care for skin all year long.

“Bathing frequently should include the use of mild soaps and avoiding hot water — it dries the skin out,” Sayre says. “And the drying process should include patting versus rubbing.

“Parents and caregivers should perform constant skin checks, and should readjust orthotics, and check cushions for wear and cleanliness. When age and cognition appropriate, children can be educated on how to complete weight shift s and on re-positioning techniques themselves.”

This article originally appeared in the January 2015 issue of Mobility Management.

In Support of Upper-Extremity Positioning