Tuesday, December 20, 2005

New Compression Stocking for Children with Lymphedema?

A new option for compression in the treatment of lymphedema in
children

Maria Elisa Simões Artíbale1, José Maria Pereira de Godoy,2 Maria de
Fátima Guerreiro Godoy,3 Domingo Marcolino Braile4

1. Physical therapist, Lato Sensu Graduate Course in Lymphovenous
Rehabilitation, Faculdade de Medicina de São José do Rio Preto
(FAMERP), São José do Rio Preto, SP, Brazil.
2. CNPq researcher. Ph.D. Adjunct professor, Service of Vascular
Surgery, FAMERP, São José do Rio Preto, SP, Brazil.
3. Occupational therapist. Professor, Lato Sensu Graduate Course in
Lymphovenous Rehabilitation, FAMERP and Clínica Godoy, São José do
Rio Preto, SP, Brazil.
4. Head of the Graduate Course, FAMERP, São José do Rio Preto, SP,
Brazil.


Correspondence:


José Maria Pereira de Godoy
Rua Floriano Peixoto, 2950
CEP 15010-020 - São José do Rio Preto, SP, Brazil
E-mail: godoyjmp@riopreto.com.br

ABSTRACT

One of the main difficulties found in the treatment of lymphedema in
children is the mechanism of compression that should be used. The
objective of present study was to report an initial experience with
infant gorgurão (cotton-polyester textile) stockings. The
difficulties found in the treatment of infant lymphedema are
described and an alternative method of compression using a gorgurão
stocking is provided.

Key-words: lymphedema, child, treatment.

J Vasc Br 2005;4(3):311-3

The term lymphedema refers to the type of edema which occurs as a
consequence of the abnormal accumulation of liquid and substances in
the tissues. This is a failure of the lymphatic draining system,
associated with the insufficiency of the extralymphatic proteolysis
of the cellular interstitium and mobilization of macromolecules.1

In children, the lymphedema is usually congenital and it may be
associated with other genetic anomalies.2 The treatment must be
started as early as possible, in order to avoid the progression,
which sometimes leads to a status of difficult reversion. The
treatment follows the principles of therapy association, which
involves the lymphatic drainage, bandages and medication therapy to
avoid infections, recommendation for mothers concerning the child's
daily activities, psychological support for the child and relatives.3-
8

One of the great difficulties found in the treatment of the
lymphedema is the stockings and bandages. The objective of present
study is to report an initial experiment with infant gorgurão (cotton-
polyester textile) stockings.

CASE REPORT

We report the case of a child who was referred to the vascular
service, at 18 months of age, with a history of lower limb edema
since birth. The mother reported that the child was referred right
after birth to a health center, with suspicion of renal problems.
However, the complementary examinations did not show any alteration.
At physical examination, a clinical diagnosis of the congenital
lymphedema was performed on both limbs (Figure 1). The treatment was
started, which included the manual lymphatic drainage, adapted to
children (cervical stimulation, compression of the abdomen and
inguinal stimulation), recommendation for hygienic care and
prevention of infections. Due to the distance between the health
center and her house, we proposed an intensive training for the
mother, so that she could perform the therapy at home. This training
lasted for 15 days and a further evaluation was required every 30
days. The mother was trained to perform the treatment at home, but
the child did not show any improvement in the follow-up visit, and
the mother reported not having enough patience for such treatment.
Due to the difficulties related to cares, we chose the adaptation,
confection and continuous use of the gorgurão stockings. This fabric
is made of polyester and cotton and, since it is corded, it presents
a different extensibility, according to the direction of the fibers.
This allows it to work as a low extensibility material, in the
opposite direction of the fibers, and medium elasticity, in the same
direction of the fibers. Therefore, these characteristics and its
resistance allow its adaptation for our needs. The stockings are made
with velcro, which offers a better adjustment, as the limb reduces
its circumference. This material can be found in fabric stores, but
it can present small variations, according to the manufacturer. For 2
consecutive years, this child was monthly followed up by the team,
which included lymphologist, physical therapist, occupational
therapist and psychologist. She presented reduction in the limb
diameter, but had great difficulties concerning the necessary cares.
The intervention of the social assistance service was always
necessary to verify the continuity of the treatment at home and other
needs detected for a better psychomotor and social development of
this child. However, during the months in which the child wore the
stockings, she presented a clinical and perimetric reduction of the
limb (Figures 2 and 3).

Figure 1 - Characteristic lymphedema of the child's foot at initial
assessment.

DISCUSSION

One of the great difficulties in the treatment of the lymphedema in
Brazilian children is the compression mechanism, both with regard to
bandages and stockings. One of the alternatives found by Godoy &
Godoy was the creation of a stocking made of gorgurão for adults,
which was adapted for children. In the present study, this adaptation
was satisfactory concerning functionality. Nevertheless, there were
difficulties regarding the awareness of the evolution of the disease
and the family and patient adherence to the treatment. The habit of
walking bare foot was a major impediment to the adherence. We
suggested that the child should go to school, where the local social
assistant, principal and teachers were informed, by our team, about
the disease, its evolution and the need for treatment, the importance
of wearing the stockings every day to maintain the reductions
achieved and to avoid the increase in the limb. This alternative
proved to be useful to make the child wear the stockings, to
encourage daily care and the psychomotor development and
socialization of this child.

A great advantage of the gorgurão is its cost, besides being easy to
wear and remove the stockings, which gives more liberty to the
patient in all activities.

This new approach, proposed for the treatment of children with
lymphedema, calls the attention to a new reality regarding the
treatment of this disease. The use of the stockings for the treatment
in children who cannot receive an effective outpatient care, either
due to the distance from the health centers or due to the socio-
economic condition, which does not allow the patient to come to the
center to be submitted to the treatment. However, the support from
the relatives is essential, or else the patients will have to rely on
the community, through professionals that can help them, in order to
maintain the therapeutic approach.

CONCLUSION

The adaptation and use of the gorgurão stockings for the treatment of
the lymphedema in children reduce the edema, making the progression
of the lymphedema slower. The effective involvement of the family
and/or community is essential to obtain good outcomes.

Vascular Journal of Brazil (2005)

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