Evidence Based Strategies: Closing the Gap - Best Practices for Pediatric Laceration Repair

From playground tumbles to kitchen mishaps, lacerations are among the most common reasons children seek medical care. This article offers an updated, evidence-based guide to pediatric laceration management, published in conjunction with a new clinical pathway: Laceration - Children’s Mercy.

Initial Assessment

First, ensure the patient’s stability and control excessive bleeding. Then, gather a history including time and mechanism of injury, relevant medical conditions (e.g., connective tissue disorders, immunocompromised), and tetanus immunization status. Consider also whether the injury is concerning for child physical abuse (Child Physical Abuse - Children’s Mercy). If the laceration is due to an animal bite, refer to the Animal Bite Clinical Pathway (Animal Bites (Mammal) - Children’s Mercy). Evaluate for associated injuries, such as fracture, tendon or cartilage involvement, or intracranial injury, as these warrant additional intervention.

Managing Pain and Anxiety

Pediatric laceration care requires an individualized approach to maximize patient comfort and cooperation. The plan will depend on the patient and on the necessary interventions. While not all lacerations should be closed, it may still be necessary to address pain and anxiety in order to examine the wound, irrigate, and remove any foreign material. Distraction, swaddling and anxiolytics can ease anxiety and improve cooperation in younger children. Options for pain management include systemic analgesia, topical or locally injected anesthetics (lidocaine + epinephrine), and regional blocks. If injectable lidocaine is used, the total dose should not exceed 5 mg/kg (max 300 mg), or if combined with epinephrine, up to 7 mg/kg (max 500 mg).¹

Irrigation

Lacerations should be irrigated copiously with tap water, either directly under a faucet or using a syringe. A 2022 Cochrane review of 13 randomized controlled trials found that using tap water does not increase rates of infection or poor wound healing when compared to sterile water or sterile saline.² After irrigation, carefully inspect the wound to assess for depth and foreign bodies or debris. Sterile gloves are not necessary for irrigation or laceration repair.³

Determining Need for Closure

Not all lacerations should be closed at the time of presentation. Small, superficial wounds, especially those on mucosa or concave surfaces (e.g., axilla, interdigital spaces), heal best by secondary intent.³ Wounds greater than 24 hours old, especially if already healing or showing signs of infection, should remain open to heal by secondary intent and the patients should be referred to a surgical specialist if future revision is required for cosmesis or function.³ Bite wounds or those contaminated with untreated water should be left open whenever possible or closed just enough to achieve hemostasis and acceptable cosmesis.³

If lacerations require a repair beyond the scope of the evaluating provider, arrange subspecialty consultation or transfer to a setting that provides the necessary intervention. These may include lacerations involving subcutaneous tissue, structures of the eye, the vermillion border, or other areas for which subspecialty expertise would be beneficial. In these cases, irrigate and dress the wound prior to transfer and consider whether the child should remain NPO in case sedation will be needed.

Approaches to Closure

Selecting a material for laceration closure should depend on wound location, depth and tension, as well as the availability of closure materials. If there is need for sedation (for closure or later suture/staple removal), or if there are barriers to follow-up care, shared decision-making should be employed to determine the best approach to closure.

• Tissue adhesive or adhesive strips (glue, Steri-Strips, Clozex, ZipStitch): Ideal for superficial wounds under minimal tension
• Absorbable sutures (e.g., fast absorbing gut or plain gut): Preferred for most pediatric lacerations, especially on the face; cosmetic outcomes are equivalent to nonabsorbable sutures^4,5 and no follow-up is required for removal
• Nonabsorbable sutures (e.g., nylon or polyethylene): Best for wounds under tension, such as those which are widely gaping or crossing a joint, as they offer greater tensile strength
• Staples: Quick and easy for scalp wounds, but must be removed in follow-up
• Hair apposition technique: Favorable alternative for scalp wounds that is painless and does not require removal

Infection Prophylaxis

Topical and systemic antibiotics are not indicated for most lacerations. Exceptions may include bite wounds, wounds with signs of active infection, wounds that are visibly contaminated or exposed to untreated water, or penetrating foot injuries through a shoe.³ Administer tetanus vaccine and tetanus immunoglobulin as indicated for unimmunized or under-immunized children. Consider rabies prophylaxis for animal bites.

Follow-Up and Aftercare

Before discharge, discuss home care, including hygiene, expectations for healing, and return precautions for infection or dehiscence. If needed, plan for follow-up for suture or staple removal. Families should be reminded that all lacerations result in scar formation. Beyond sun protection, little evidence exists for scar reduction; some studies suggest that scar massage and topical vitamin E may help.³

Management of lacerations is widely variable based on mechanism of injury, anatomic location, patient characteristics and family preferences. By completing a thorough assessment and creating a tailored, evidence-based approach, you can provide the patient optimal comfort and cosmesis while decreasing the risk of complication. 

References:

1. Peterson SJB, Weisman SJ. Pediatric pain management. In: Kliegman RM, St. Geme III JW, Blum NJ, et al, eds. Nelson Textbook of Pediatrics. 22nd ed. Elsevier Inc.; 2025:677-700.
2. Fernandez R, Green HL, Griffiths R, Atkinson RA, Ellwood LJ. Water for wound cleansing. Cochrane Database Syst Rev. 2022;9(9):CD003861. doi:10.1002/14651858.CD003861.pub4

3. Silverberg B, Moyers A, Wainblat BI, Cashio P, Bernstein K. A stitch in time: operative and nonoperative laceration repair techniques. Prim Care. 2022;49(1):23-38. doi:10.1016/j.pop.2021.10.008
4. Basyuni S, Ferro A, Jenkyn I, et al. Randomised controlled trial of resorbable versus non-resorbable sutures for lacerations of the face (TORN Face). Br J Oral Maxillofac Surg. 2024;62(7):642-650. doi:10.1016/j.bjoms.2024.05.012
5. Malhotra K, Bondje S, Sklavounos A, Mortada H, Khajuria A. Absorbable versus nonabsorbable sutures for facial skin closure: A systematic review and meta-analysis of clinical and aesthetic outcomes. Arch Plast Surg. 2024;51(4):386-396. doi:10.1055/a-2318-1287