PAEDIATRIC NURSING April 2009 | Volume 21 | Number 3
In a multi-centre, observational study, Clare Morris and colleagues
evaluated the effectiveness of the Mepilex® Border Lite dressing
Use of wound dressings with
soft silicone adhesive technology
Children are frequently exposed to physical
trauma which may result in external or internal
wounding. There are a number of clinical challenges
in relation to wound management in children.
First, and of significant importance, is the pain
suffered by patients, either in relation to the
wounds themselves, underlying pathologies,
or as a result of trauma caused by therapeutic
interventions such as dressing-related procedures.
Pain can lead to stress, the psychological aspects
of which are just as important to manage as the
pain itself. Pain-induced stress can delay wound
healing and adversely affect patients’ quality of
life (Soon and acton 2006). it has been shown that
patients experience most pain at dressing changes
(hollinworth and Collier 2000).
although analgesia and anaesthesia can be used
to help reduce pain during dressing changes, these
have cost implications for healthcare providers and
carers, and some analgesic and anaesthetic agents
Aim: To evaluate how pain, during and in-between dressing changes, is affected by the introduction of Mepilex®
Border Lite, a wound dressing using Safetac® soft silicone adhesive technology, to the treatment of different
types of paediatric wounds/skin injuries.
Methods: Wounds/skin injuries that met the criteria for inclusion in the study were dressed with Mepilex®
Border Lite. Patients were followed for six weeks or until their wounds/skin injuries had healed, whichever
occurred earlier. At each dressing change, pain severity before and during dressing removal was rated by
the patient and the investigator on a scale from zero (no pain at all) to ten (worst pain ever). Other variables
measured at dressing changes included: signs of trauma to wound/skin injury and surrounding skin, the
proportion of viable/non-viable tissue, the quantity and appearance of exudate, odour, and clinical signs of
infection. At the final dressing change, patients and investigators completed simple questionnaires to rate the
Results: Mean pain severity scores were significantly lower (p ≤ 0.003) at the first dressing change than at
baseline. Over 99.5 per cent of the Mepilex® Border Lite dressing changes were reported to be atraumatic and
more than half of the wounds healed within the study period. Conformability, ease of use, ease of removal,
patient comfort, and overall experience with the dressing were rated as “good” to ‘very good’ at the vast majority
of final visit evaluations.
Conclusions: This study provides further evidence of the ability of dressings with Safetac soft silicone adhesive
technology to minimise trauma and pain and demonstrates the ability of Mepilex® Border Lite to overcome the
clinical challenges associated with the use of dressings on the wounds/skin injuries of paediatric patients.
Keywords Wounds, Dressings, Children: accidents. This article has been subject to open-peer review.
PAEDIATRIC NURSING April 2009 | Volume 21 | Number 3 39
injuries such as burns, traumatic wounds (cuts,
scrapes, skin tears, abrasions, finger/toe injuries,
and blisters), and surgical wounds.
The primary objective of the study was to evaluate
how pain is affected during and in-between dressing
changes by the introduction of soft silicone
dressings to the treatment of different types of
wounds/skin injuries in children. The secondary
objectives of the evaluation were to assess:
n levels of trauma.
n The healing of wounds/skin injuries.
n The condition of the surrounding skin.
n The performance of the dressing in terms of
exudate handling, conformability, ease of use, ease
of removal and patient comfort.
This multi-centre, observational study included
inpatients and outpatients. inclusion criteria were
that the patients were ≤ 16 years, had wounds and/
or skin injuries that were deemed suitable to be
dressed with Mepilex® Border lite and for whom
informed consent was given. Those patients for
whom following the protocol would be difficult,
or who had a known allergy or hypersensitivity
to any of the dressing components, or had severe
underlying disease that may have interfered with
treatment were excluded.
at the first consultation, baseline demographic data
(age, gender, medical history) and history of the
wound/skin injury were recorded. any previously
applied dressings were removed and details of
the name and type of the dressings were recorded
The following parameters were measured at
the baseline visit and at all subsequent dressing
n Pain severity before dressing change.
n Pain severity during dressing change.
are associated with undesirable side effects (Soon
and acton 2006). Second, due to the small size of
paediatric wounds and the difficulties associated
with dressing unusually shaped wounds in
awkward locations, such as wounds resulting from
digit and limb injuries, clinicians need access to
highly flexible and conformable dressings.
in addition to managing wound pain and
overcoming the difficulties posed by the size and
location of wounds, clinicians must also deal with
the normal challenges of tissue viability, such
as effectively controlling exudate, preventing
the ingression of foreign bodies (dirt, bacteria),
and negating malodour, in a wide variety of
wound types. The dressings they select must be
appropriate for these multiple purposes.
according to a World Union of Wound healing
Societies (2004), the following dressing parameters
should be considered to help minimise trauma
and pain during dressing-related procedures:
maintenance of moist wound healing, fluid
handling capacity, atraumatic to the wound and
skin, and low allergy potential.
Mepilex® Border lite is a thin, absorbent,
self-adhesive island dressing with a perforated
soft silicone adhesive (Safetac®) wound contact
layer that adheres readily to intact dry skin but
does not stick to the surface of a moist wound
and does not cause damage on removal (White
2005). The absorbent core of the dressing consists
of two layers. The first layer, a thin sheet of
polyurethane foam, transports exudate away
from the wound to the second layer, a piece of
non-woven fabric, which spreads the exudate
horizontally. The dressing also possesses a
vapour permeable backing film through which
the exudate evaporates from the wound pad. The
fluid handling system of Mepilex® Border lite,
in addition to its soft silicone adhesion layer
inhibiting the lateral movement of exudate from
the wound to the surrounding skin, helps to
minimise the risk of maceration (Thomas 2003).
Mepilex® Border lite has been designed for
situations where clinicians require a thin and
highly conformable dressing for anatomical or
practical purposes, and where fluid handling
requirements are low, that is low exuding wounds
such as leg and foot ulcers, pressure ulcers and
traumatic wounds such as blisters and skin tears.
it is available in five sizes, of which the smaller
ones are particularly suitable for the size and
location of wounds in children.
a multi-centre, observational study was
undertaken to evaluate the use of Mepilex® Border
lite on different types of paediatric wounds/skin
Table 1 Wound demographics at baseline (n=36)
Wound typeBurn (n=10)
Wound duration (mean [mini-max])8.9 (1-60) days
Proportion of viable tissue (mean [mini-max])89.5 (30-100) per cent
*Cannula insertion site (n=1); skin lesion post-herpes zoster (n=1)
PAEDIATRIC NURSING April 2009 | Volume 21 | Number 3
n Clinical signs of trauma to wound/skin injury
and surrounding skin.
n Condition of the surrounding skin.
n Percentage of viable/non-viable tissue
(qualitative visual assessment).
n exudate amount (recorded using the standard
terms of ‘none’, ‘low’, ‘moderate’ or ‘high’)/
nature (recorded as ‘clear (serous)’, ‘yellow/
green’, ‘brown/blood’ or ‘other’.
n Presence of malodour.
n Clinical signs of infection.
n debridement (whether or not performed).
n Patient subjective symptoms.
Rating pain severity
Pain severity, before and during dressing change,
was rated by the patient and the investigator on a
scale from zero (no pain at all) to ten (worst pain
ever). To facilitate this, a pain assessment tool,
based on the Visual analogue Scale (VaS) and the
Wong-Baker Faces Scale, was used (harms-ringdahl
et al 1986; Keck et al 1996). if the investigator felt
that this pain assessment tool was not appropriate
for use with a particular patient, for example if
the patient was unable to verbalise the presence
or severity of pain), then they used the Faces,
legs, activity, Cry and Consolability (FlaCC)
Behavioural Pain assessment Scale for quantifying
pain behaviours (Merkel et al 1997).
Photographs of the wounds/skin injuries were
taken to monitor their size and condition. at
the final dressing change, the patients and the
investigators completed simple questionnaires to
rate the dressing in terms of conformability, ease
of use, ease of removal, and comfort.
The investigators selected the most appropriate
size of Mepilex® Border lite (chosen from one
of the five different sizes available) and applied
it to the wound/skin injury. Combining this
dressing with other dressings was acceptable
if, in the opinion of the investigators, there was
clinical justification to do so. investigators were
allowed to cut the borders of the dressings if it
was felt that this would facilitate application to
flexion points. dressing changes were performed
when judged necessary by the investigators at
frequencies that they felt were compatible with
good exudate management.
each patient was followed for six weeks or
until the wound/skin injury had healed, whichever
occurred earlier. at any point during the study,
the investigators had the option of discontinuing
treatment with Mepilex® Border lite if, in their
opinion, the dressing was no longer appropriate
for a particular patient. any untoward and/
or unintended response that was possibly or
probably related to the dressing were recorded on
the case study form.
electronic searches of bibliographic databases
(Medline, national library of Medicine,
Bethesda, USa; eMBaSe, elsevier BV, amsterdam,
netherlands) and internet sites (Cochrane library,
World Wide Wounds) were supplemented with
manual searches of journals of relevance to wound
management to identify articles, published up
to and including 2007, that describe evaluations
of dressings and pain-relieving strategies on
paediatric patients in which pain severity scores
were recorded. relevant studies are included in
the discussion section below.
descriptive statistics (mean and standard deviations)
were applied to the primary and secondary objectives
when quantitative data were established. a t test was
used to analyse the pain severity scores measured
at baseline versus those recorded at the subsequent
dressing change (first visit).
Thirty-six patients (boys, n=23; girls, n=13)
with a mean age of 7.6 years (range nine days –
15 years) with a variety of wound types
satisfied the criteria for inclusion in the study.
Table 1 summarises the wound demographics
at the baseline assessment. Various wound
dressings were removed at baseline, for example,
absorbent cellulose, hydrocolloid, honey gel, film
and foam. during the study, one patient died (the
cause of death was not related to the dressing),
one patient was withdrawn (he was unable to
attend the clinic for follow-up dressing changes) and
five patients were withdrawn as a result of the
investigators deciding to switch to alternative
Table 2 Number of patients demonstrating changes in pain severity scores
at first dressing change
Prior to dressing
At dressing change
At dressing change
1 1 2
PAEDIATRIC NURSING April 2009 | Volume 21 | Number 3 41
dressings that they believed to be more appropriate.
The data relating to the patients who did not
complete the study were, however, included in
the final analysis.
Pain: The pain severity scores reported at the
baseline visit were statistically significantly
higher than those recorded at the first visit, that
is the first dressing change with Mepilex® Border
lite Mean score prior to dressing change was
2.58 at baseline and 0.88 at the first visit (p =
0.0005); mean score at dressing removal (patient
evaluation) was 2.84 at baseline and 1.34 at the
first visit (p = 0.0002); mean score at dressing
removal (investigator evaluation) was 2.5 at
baseline and 1.35 at the first visit (p = 0.003)
(Figure 1). The numbers of patients demonstrating
decreases, increases and no changes in pain
severity from baseline to first visit are presented
in Table 2. analgesia use at initial dressing change
was only required for two (6 per cent) patients. Of
a total of 194 dressing changes involving Mepilex®
Border lite, analgesia was only used at five (3 per
cent) of them.
Trauma: Of the 194 dressing changes involving
Mepilex® Border lite that were evaluated, 193
(99.5 per cent) were reported to be atraumatic.
Wound healing: Within the study period, 20
(56 per cent) wounds healed completely (mean
14.5 days, range four to 42 days). in terms of
the ratio of viable tissue (healthy granulation/
re-epithelialisation) tissue to non-viable
(sloughy/necrotic), wounds exhibited a
statistically significant larger proportion of
viable tissue at the final visit (mean 99.5 per cent,
Sd 1.9) than at baseline (mean 91 per cent,
Sd 17.8) (p = 0.01).
Exudate management: The wounds treated with
Mepilex® Border lite were typically associated with
low-to-moderate levels of clear (serous), yellow/
green or brown/blood coloured. There were no
reports of leakage. Malodour was reported at two
of the dressing changes.
Peri-wound skin: The proportion of patients
exhibiting healthy/intact skin around their wounds
increased from 75 per cent at baseline to 92 per
cent at the final visit.
Adverse reactions: Two adverse events were
reported during the study, neither of which was
considered by the investigators as being likely
to have been related to the use of the dressing.
One patient developed an eczematous rash (the
patient concerned has a long history of eczema-
related problems). another patient experienced an
Overall evaluations (final visit)
in terms of the overall pain that was experienced
during the use of Mepilex® Border lite, the
patients themselves recorded mean pain severity
scores of 0.23 prior to dressing change and 0.80
at dressing change. Patients gave a mean rating
of 8.38 out of ten for the overall performance of
the dressing. a summary of the investigators’ final
visit evaluations are presented in Figure 2. at the
final visit, the investigators were asked to identify
which dressing they would choose if they could
repeat the evaluation on each of their patients.
Mepilex® Border lite was chosen as the ideal
dressing for 80 per cent of the wounds and other
types of dressings with soft silicone adhesive
technology were chosen for a further nine per cent
of the wounds.
Figure 1 Mean pain severity scores prior to and at first visit
(first dressing change with Mepilex® Border Lite
Prior to dressing
At dressing change
At dressing change
Mean pain score (VAS)
■ Baseline ■ First visit
PAEDIATRIC NURSING April 2009 | Volume 21 | Number 3
Figure 2 Investigator’s evaluations at final visit
Handling at application
Ease of removal
Percentage of responses
■ Very good
The primary objective of this study was to
evaluate how pain, during and in-between
dressing changes of paediatric wounds/skin
injuries, is affected by the introduction of
Mepilex® Border lite. These results demonstrate
that this dressing can significantly reduce pain
severity both before and during dressing change.
The literature review identified six articles
related to children which incorporate pain
severity scores (based on VaS or equivalents)
relating to the use of other dressings and
pain-relieving strategies: Platt et al (1996),
Gotschall et al (1998), letouze et al (2004),
Borland et al (2005), Cassidy et al (2005), Van
Twillert et al (2007). The low pain severity scores
associated with Mepilex® Border lite compare
favourably to those reported for a number of
other dressing types and pain-relieving strategies,
even though analgesia usage appears to have been
far greater in some of the published studies. For
example, in letouze et al’s (2005) study involving
100 patients with a variety of wounds (acute,
chronic and burns) treated with a lipidocolloid
dressing, it was reported that analgesia was
administered at 21 per cent of dressing changes,
whereas in this study analgesia was used at only
three per cent of dressing changes. Therefore, as
well as reducing pain severity before and during
dressing change, the use of Mepilex® Border lite
may be associated with a need for less analgesia
The most likely explanation for the reduction
in pain severity scores reported after the
introduction of Mepilex® Border lite is the
fact that dressings with soft silicone adhesive
technology are associated with atraumatic
dressing changes and can be easily removed
without causing trauma to wounds or surrounding
skin (White 2005).
as healing progresses, wound exudate levels
decrease, thereby reducing the propensity for
trauma to peri-wound skin. a significant factor
in managing this process is the selection of
dressings that provide the optimum environment
in which wounds can progress to healing and
effectively manage wound fluid. Thus, the
dressing selection needs to be based on the
condition of the wound and peri-wound skin and
should be adjusted to accommodate changes
in these parameters. in addition to patients
experiencing atraumatic dressing changes and
minimal pain before and during dressing
removal, their wounds demonstrated good
progression to healing during treatment with
Mepilex® Border lite.
Conformability, ease of use, ease of removal,
patient comfort, and overall experience with the
dressing were rated as ‘good’ to ‘very good’ by
the vast majority of the investigators’ at final visit
evaluations. investigators commented mainly on
the physical handling of the dressing with regards
to it staying in place. They were generally positive
about the flexibility and conformability of the
dressing when applied to wounds that were small
and in awkward positions, such as the fingers
and toes of small children. Figure 3 shows the
dressing on an amputation wound on the fifth
digit demonstrating excellent conformability and
flexibility. Comments also indicated that dressings
were easy to apply and remove.
a significant clinical challenge with small
children is keeping the dressing in place and in
many cases additional fixation was required for
dressing retention. The reasons given for the
lack of adhesion in this study included: patients
interfering with their dressings, patients’ active
lifestyles exacerbating adhesion problems,
and positions of the wounds making dressing
adherence to skin problematic. These are issues
commonly encountered in dressing wounds in
children. Some investigators also indicated that
Research Download full-text
PAEDIATRIC NURSING April 2009 | Volume 21 | Number 3 43
the dressing could be maintained in place for
several days, providing good protection against
foreign material ingress.
Positive feedback from the patients and/
or their parents was also much in evidence in
the case study forms. The patients gave a mean
rating of 8.38 out of ten for the dressing’s overall
performance. The response was especially positive
with regards to comfort, flexibility and ease of
use. There were a number of reports of reduced
distress and anxiety, together with a reduced need
for analgesia, after the introduction of Mepilex®
Border lite. One significant comment was from
a parent who indicated that, during treatment
with Mepilex® Border lite, the heart monitor to
which her infant was connected did not show
the increased heart rates that had been observed
during the application and removal of other
Trauma and pain associated with the removal of
wound dressings is of major concern to patients
and healthcare professionals. Furthermore, the
trauma to the wound bed and surrounding skin
that can occur with excessive dressing adhesion
prolongs the duration of wounds, resulting in
increased treatment costs and morbidity.
not surprisingly, many clinicians involved in
the field of wound care are becoming
increasingly reluctant to prescribe traditional
These issues were carefully considered in
designing the study protocol. While recognising
the importance of comparator groups in clinical
evaluations, it was felt that, for this particular
study, there was no obvious candidate to evaluate
alongside Mepilex® Border lite and to have used
a traditional adhesive wound dressing with the
potential to cause trauma and pain would have
been unethical, particularly in view of the study
The size of the sample (36 participants) was
deemed to be in line with other studies that
have evaluated dressings and interventions in
paediatric wound management.
This study was undertaken to evaluate the
impact of introducing Mepilex® Border lite into
the treatment regime of children and young
people with a variety of wound types. The results
show that this product addresses the major
challenges that clinicians face when treating such
wounds, that is, the need to use dressings that
are atraumatic and minimise pain on removal,
and that have sufficient flexibility and
conformability to stay in place when applied to
small wounds in awkward locations. Moreover,
Mepilex® Border lite has been shown to be
capable of promoting a wound healing
environment that is conducive to healing,
managing low-to-moderate levels of exudate, and
preventing maceration of peri-wound skin.
Clare Morris is Tissue
Viability adviser, North East
Wales NHS Trust, Wrexham
Paulene Emsley is Tissue
Viability nurse specialist,
Royal Hospital for Sick
Elizabeth Marland is
Nurse, Trafford Healthcare
NHS Trust, Manchester
is advanced nurse
practitioner, Wound Care
Centre, Zottegem, Belgium
Richard White is senior
research fellow, Grampian
NHS Acute Trust, Aberdeen
This study was funded by
Molnlycke Health Care. None
of the authors has an interest
in the sponsor’s commercial
Acton C (2007) The holistic management of chronic
wound pain. Wounds UK. 3, 1, 61-69.
Borland ML et al (2005) intranasal fentanyl is an
equivalent analgesic to oral morphine in paediatric
burns patients for dressing changes: a randomised
double-blind crossover study. Burns. 31, 7, 831-837.
Cassidy C et al (2005) Biobane versus duoderm for the
treatment of intermediate thickness burns in children:
a prospective, randomised trial. Burns. 31, 7, 890-893.
European Wound Management Association (2002)
Position Document: pain at wound dressing changes.
Medical education Partnership, london.
Gotschall CS et al (1998) Prospective, randomised study
of the efficacy of Mepitel on children with partial-
thickness scalds. Journal of Burn Care Rehabilitation.
Harms-Ringdahl K et al (1986) Pain assessment with
different intensity scales in response to loading of joint
structures. Pain. 27, 3, 401-411.
Hollinworth H, Collier M (2000) nurses’ views about
pain and trauma at dressing changes: results of a
national survey. Journal of Wound Care. 9, 8, 369-373.
Keck JF et al (1996) reliability and validity of the Faces
and Word descriptor Scales to measure procedural
pain. Journal of Pediatric Nursing. 11, 6, 368-374.
Letouze A et al (2004) Using a new lipidocolloid
dressing in paediatric wounds: results of French and
German clinical studies. Journal of Wound Care. 13, 6,
Merkel SI et al (1997) The FlaCC: a behavioral scale for
scoring postoperative pain in young children. Pediatric
Nurse. 23, 3, 293-7.
Platt AJ et al (1996) a comparative study of silicone net
dressing and paraffin gauze dressing in skin-grafted
sites. Burns. 22, 7, 543-545.
Soon K, Acton C (2006) Pain-induced stress: a barrier to
wound healing. Wounds UK. 2, 4, 92-101.
Thomas S (2003) atraumatic dressings. World Wide
Wounds. available online at: www.worldwidewounds.
(last accessed: February 26 2009.)
White R (2005) evidence for atraumatic soft silicone
wound dressing use. Wounds UK. 1, 3, 104-109.
Van Twillert B et al (2007) Computer-generated virtual
reality to control pain and anxiety in pediatric and
adult burn patients during wound dressing changes.
Journal of Burn Care and Research. 28, 5, 694-702.
World Union of Wound Healing Societies (2004)
Principles of best practice: Minimising pain at wound
dressing-related procedures. a consensus document.
available online at: www.wuwhs.org/datas/2_1/2/a_
dressing_related_procedures.pdf (last accessed:
February 26 2009.)
Figure 3 Finger amputation wound dressed with
Mepilex® Border Lite