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Abstract:
Pressure ulcers are localized damage to the skin from an applied force over a period of time. The
applied pressure, if not treated, will aggregate blood cells as well as damaging capillaries, which
causes necrosis and cell destruction. In adults, ulcers are most likely to develop in the sacrum
and heel regions. In children, especially those 12 months or younger, ulcers may occur within the
scalp region. Despite recent pediatric recommendations promoting pressure distribution
surfaces, few studies exist assessing peak pressure points in children and methods to prevent
pressure ulcer development. Thus, the objectives of this pilot study were to: i) Identify the
location of peak pressure and corresponding contact area while children (age 3-5) lay supine; ii)
Assess the differences in peak pressure/contact area between two surfaces (crib mattress/yoga
mat); iii) Determine correlation between peak pressure and child weight.
Preliminary results indicate the peak pressure point for children is at the scalp region opposed to
the sacrum/heel in adults. Higher peak pressure over a smaller contact area is present on the
yoga mattress compared to the crib mattress.
I. Introduction
Pressure ulcers, commonly known as bedsores, are defined as localized damage to the
skin and underlying tissue over any bone prominence, including the joint region such as the heels
or elbows. Applied pressure is the amount of force placed on an object perpendicular to the its
pressure mattresses, that can visually indicate regions via color coding or numerical values.
There have been many studies related to ulcer development in adults, some in which define
maximum loads before injury or prominent development regions; however, there is a lack of
evidence to suggest both the maximum load of applied pressure before injury and the location of
As mentioned previously, pressure ulcers are defined as localized damage to the skin over
bony prominences. If not treated, the applied pressure will lead to blood cell aggregation,
damage to capillary walls of the skin, and necrosis/cell destruction (Wounds International).
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contract with a surface causes skin tissue to press up against a bony prominence. The pressure
created from the bone causes three stresses to occur: (i) shear, (ii) tensile, (iii) compression.
Shear stress is defined as the parallel force applied to the skin’s surface, in other words, it is the
amount of friction applied on the skin tissue. Tensile stress, or tension, is the perpendicular force
in the skin which occurs during this state of contact. And lastly, compression stress is the applied
force between both surface and bone. All three stresses cause the skin to stretch and break down
as the pressure load increases or remains constant over an extended period of time (Curley).
According to the article Pressure Ulcers in the Surgical Patient by Drs. Susan Shoemake and
Mercury), or 0.618777 psi (Pound-force per Square Inch), to the skin places an adult patient at
For adults, common ulcer development occurs mainly in the lower regions of the body.
These regions include the sacrum, heels, knees, ankles, and even in upper joint areas such as the
elbows or shoulders. Both the joint and sacrum regions are known for their larger bony
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prominences, and due to the large amount of activity most adults partake in, various amounts of
pressure are applied daily to the skin (Allman, Goode, Burst, Bartolucci, & Thomas). Ulcer
development can also be attributed to the level of comfort applied towards these mentioned
regions; for example, if an individual were to sit on a surface that they would deem
uncomfortable for over a certain period of time, they would experience soreness in their sacrum
For children, mainly infants, pressure injuries mainly occur in the developmental regions:
the scalp and the sacrum. Since infants mostly remain immobile for the first few months of their
lives, it is important for the parent to monitor the position of the infant at all times. The infant
shouldn’t always remain lying down on its back since the amount of pressure over time will
cause injury towards the head. Also, when lying on its back for a long period of time, the head
should remain propped up on a soft, yet firm surface to ensure comfort and reduce any
Other known causes of pressure ulcer development can occur due to a patient’s
compromised mobility. Having impaired mobility can lead to difficulties reliving interface
pressure, resulting in impaired circulation of the skin and ulcer formation. The use of medical
casts or braces can also lead to ulcer development due to the excessive amounts of applied
pressure/circulation occurring in the body. If not relieved on a regular basis, there will be a
substantial risk of ulcer formation. Lastly, patients with poor tissue integrity are also known to
have a low tolerance to various loads of applied pressure, leading to possible ulcer development
surfaces are used. These surfaces are designed to both monitor these regions and prevent
pressure related injuries via redistribution. There are two specified categories for pressure
redistribution surfaces: static and dynamic. In a review written by Madhuri Reddy (2006), he
defines static pressure redistribution surfaces as mattresses or mattress overlays that are filled
with air, water, mesh, or gel (sometimes a combination of these elements). Meanwhile, a
dynamic support surface helps mechanically vary the distribution of pressure based on the
applied pressure from the patient. The most famous example of this dynamic support surface is
the alternating pressure mattress which produces both high and low pressures between both the
This research focuses on static pressure redistribution for the following reasons. Static
redistribution surfaces offer a variety of comfort levels towards a patient, especially infants, that
are proven to be safe. Soft bedding surfaces, such as sheep skin or cloth, are beneficial towards
infants due to their softness and low-risk of inhaling fabric particles or other toxins that could
come from other surfaces or blankets. Dynamic surfaces, such as low-air pressure mattresses,
have been shown to give a high risk towards skin breakdown, especially when turning, in some
pediatric studies. To prevent such a risk from occurring, it is recommended to turn the infant
patient every 1-2 hours, which ultimately limits the effectiveness of a dynamic surface (McCord
et. al).
The goal of this research is to conduct a pilot study that identifies the pressure points of
children lying on two different mattress surfaces, a crib and yoga mattress. While performing this
study, predictions were made that there will be a correlation between the amount of contact
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pressure and the child’s weight, as well as the highest amount of contact pressure being present
The data was obtained via pressure sensor (Tekscan 5400N) and the Tekscan Body
Pressure Measurement System (BPMS) research software, measuring out the amount of pressure
(mmHg) and contact area (in2). An approved IRB form was given for each participant, assuring
II. Methodology
To obtain pressure data, this study utilizes different mattress surfaces, a pressure sensor,
and a pressure measurement program (BPMS) for analysis. Child participants would lie on top of
the mattress while the sensor retrieved their pressure data. This data is further extracted and
Equipment:
The conducted study focuses on the use of two mattress surfaces to measure a difference
of recorded contact pressure. The first mattress used was the “Heavenly Dreams White Crib and
Toddler Mattress” by Safety 1st. This mattress weighs approximately 50 lbs., and measures at
52.5” x 27.5” x 5.5” according to its product description via Amazon. The purpose for using this
sleeping in a bed. The second mattress was a yoga mattress by the company Series-8 Fitness.
This mattress is somewhat thicker than standard yoga mats for added comfort, as stated by the
packaging, and measures at 24” x 68” x 0.1969”. The purpose for using the yoga mattress in the
study was to obtain the highest amount of contact pressure possible as the child would lie closest
to the floor. On top of these mattresses is the applied pressure sensor, the Tekscan 5400N, that
The method of measurement for pressure and contact area will come from a medical
sensor from the company Tekscan, known as the Medical Sensor Model 5400N Body Pressure
Measurement System (BPMS). Table 1 below displays its technical information, while Figure 2
1060.0 640.0 120.0 578.0 884.0 10.0 17.0 34 10.0 17.0 52 1,768 0.3
Table 1. Medical Sensor 5400N (Tekscan) Parameters
These parameters help define the 5400N sensor. This sensor can withstand applied
1,768 sensels (or sensor cells) placed within the sensor as shown in Figure 2 above. Since a
single sensor only covers roughly half of the mattress, another sensor was purchased to help
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cover the full body. Data from both these mattresses are merged on the BPMS CONFORMat
Tekscan’s Body Pressure Measurement Software was used to obtain the pressure and
contact area data. Using two 5400N CONFORMat sensors and their connector ports (as shown in
Figure 3), the program records pressure data in real-time at a sampling rate of 10 Hz/s or 22,880
sensel data/s, and saves pressure data within a program compatible video file.
The pressure mapping can be further analyzed by selecting different areas of the body
with a customized window (sample shown in Figure 4A). The data is then taken from each
individual region and put into graphical form (seen in Figure 4B), with the option to further
(A) (B)
Figure 4. (A) Sample Peak Pressure Data; (B) Sample Body Map
These figures were used to extract pressure and contact area per selected region. The
regions analyzed for this study are the head, back, sacrum, both elbows, and both heels. Since the
analyzed data is raw, a moving average was applied in the extracted Excel files to filter out any
possible outliers and to give an accurate measurement of high peak pressures per region.
Experimental Design:
With the consent of the participants, measurements such as height, weight, and other
regions were taken to help calibrate the sensitivity of the 5400N sensors (see Appendix A for
measurement diagrams). Calibrating the sensors towards the subject’s weight helps assure
accurate measurements for both peak contact pressure and the contact area. The pressure sensors
were placed inside a mattress cover, provided by Tekscan, and were set atop the mattresses (see
Figure 5).
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Figure 5 displays the cover used in this study. The marked areas display the regions
where participants had to lie in. The two outermost regions were used to indicate how far out the
hands and elbows should lie so the 5400N sensors can pick up the pressure data, while the
middle region is where the participant should lie on. After measurements were made, a quick
calibration test was done by having the subject lie on and off the mattress for 60 seconds. Once
the sensitivity is set, the subject was tasked to lie on the mattress for approximately 10 to 30
seconds (each 0.6 seconds being a frame of data). This process was done for both mattresses due
Data Analysis:
The extracted data was analyzed through the Microsoft Excel program. Since the data
was raw, a moving average was applied to remove outliers and to ensure accuracy of the peak
pressure and contact area. After filtering the dataset, the maximum and means of each region was
calculated and then compared per subject. Overall averages for both the max and mean data was
given and further compared between both mattress surfaces. Furthermore, the correlation
between the subject’s weight and the contact peak pressure was also analyzed and compared,
III. Results
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Four children participated in this study, with an age ranged from 3 to 5 years old (4 years
old on average). Specific subject data is shown in Table 2, while body measurements is given in
Figure 6.
SUBJECT MEASUREMENTS
44
43
39.8
39
39
34.8
33.5
35
35
31.8
30.25
30.5
26.5
28
LENGTH (IN)
24
24
21.5
20.25
20.5
22
18.75
19.5
20
19
10.5
10.5
12
11
11
9.5
9.5
10
8.5
9
8
7
WEIGHT STATURE ACROMIAL WAIST TIBIALE THUMP-TIP HEAD SHOULDER- FOREARM-
(LBS) ELBOW HAND
MEASUREMENTS (SUBJECTS 1 - 4)
Figure 6. Subject Measurements in Various Regions
Figure 6 compares measurements of the selected regions for all four subjects. While the
subject’s weight is vital in terms of calibrating the mattress’s sensitivity, these other
measurements feature the prominent areas in which the pressure points exist.
After these measurements were made, participants lied on top of the pressure sensor for
approximately 10-30 seconds and their data was extracted focusing on the following regions of
peak pressure and contact area: head, back, sacrum, elbows, and heels. The maximum and mean
values for all frames of data in each boxed region were calculated and compared between all
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participants in the study. The purpose of comparing both the max and mean data for each subject
per region was to identify a common region of highest peak pressure. In Figure # below, the
average values (peak pressure and contact area) between all four subjects were compiled and
compared between both mattresses for both the maximum and mean values for each region.
100 100
Peak Pressure (mmHg)
60 60
40 40
20 20
0 0
Sacrum Chest Head Left Left Heel Right Right Sacrum Chest Head Left Left Heel Right Right
Elbow Elbow Heel Elbow Elbow Heel
Regions Measured Regions Measured
50 50
Contact Area (in^2)
Contact Area (in^2)
40 40
30 30
20 20
10 10
0 0
Sacrum Chest Head Left Left Heel Right Right Sacrum Chest Head Left Left Heel Right Right
Elbow Elbow Heel Elbow Elbow Heel
Regions Measured Regions Measured
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Figure 7. Subject Peak Pressure and Contact Area (Mean and Max)
After examining the maximum and minimum values per region, the correlation between
peak pressure and weight was observed. Each region was examined for all four participants
between each of the different mattresses. Like previous, both the maximum and mean values
were compared. Figure 8 A-B below includes the highest regions of peak pressure, the head and
60
3 25 2
50
2 20 3
40
15
30
10
20 y = 0.9323x + 26.41 y = 0.3297x + 16.494
10 R² = 0.1773 5 R² = 0.0372
0 0 Max Subject Contact Area (n = 4)
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) 60 WeightCrib
(lbs.) Yoga
120 70 40
4 60
100
1 30 1
Peak Pressure (mmHg)
50
80 3 20 y = 2.7087x - 56.503
2 40
R² = 0.8792 43
60
30
10 2
40 y = -0.434x + 102.89
20 0
R² = 0.0098 Sacrum Chest Head Left Left Heel Right Right
20 Elbow Elbow Heel
10
Regions Measured
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) Weight (lbs.)
Figure 8A. Correlation of Weight and Peak Pressure (Mean Data)
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y = 3.1399x - 69.913
3 50
80 R² = 0.872
2 40 3
60 4 2
30
40
20
y = 0.4061x + 81.31
20 10
R² = 0.0072
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) Weight (lbs.)
IV. Discussion
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The obtained data demonstrates the possibility of peak contact pressure a child can
experience when active or inactive in their daily lives. In Figure 7, all four subjects on average
experienced higher peak contact pressure while lying down on the yoga mattress in every
measured region. The highest region of peak pressure occurred in the head, followed by the
sacrum on both the crib and yoga mattresses. The contact area in each region was higher on the
crib mattress, this was because contact pressure is widely and evenly distributed on a thicker,
more comfortable surface than on the yoga mattress, where contact pressure was more direct
towards the ground. This supports the hypothesis of the head region experiencing the highest
With the correlation between child weight and contact pressure, seen in Figure # A and
B, the head and sacrum regions had the highest correlations compared to the others which were
significantly low. Looking through both the max and mean datasets, the highest possible
correlation achieved was in the sacrum region when the child lied down on the yoga mattress
(Figure 8A displays this in the bottom right graph). This also supports the given hypothesis for
The correlation between an individual’s weight and the contact pressure they experience
with any surface is a common study, especially when developing comfort-based products.
Products such as foot inserts exist to reduce discomfort in shoes while walking and to prevent
any skin or muscle breakdown in the heels. In a study titled “The impact of increasing body mass
on peak and mean plantar pressure in asymptomatic adult subjects during walking” by John B.
Arnold and his research team, pressure data was obtained using three different types of stances
while walking with weighted vests (0 – 15 kg). This research examined several regions of the
foot: hallux, the toes, all five metatarsals, the midfoot, and the heel. As hypothesized, the applied
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pressure increased in all regions when more weight was applied. Although this research was
aimed towards observing heel contact pressure in both diabetics and non-diabetics, the
correlation between the two factors helps support this pilot study.
Moving Forward:
This study can be expanded upon for future research utilizing different factors as well as
expanding upon the ones already included. Different surfaces that the child can lie on can be
considered, such as the use of foam, gel, or air mattresses. Each of these surfaces are known to
have different methods of pressure distribution and their contribution towards the subject’s
overall peak contact pressure can vary tremendously. Having a wider participant age range, from
infancy to early grade school (approximately 7 years), can also impact the weight/pressure
correlation and with more participants comes a larger variety in obtained measurements.
Other examinations can revolve around types of posture and positioning of an infant. In
the research article, Infant trunk posture and arm movement assessment using pressure mattress,
inertial and magnetic measurement units (IMUs) by Andraz Rihar and his research team, their
goal was to examine the kinetics of the arm and trunk of an infant when placed on a pressure
mattress. This research involved the use of multiple IMUs (inertial measurement unit), pressure
sensors, and infrared LED cameras, to focus on obtaining information for non-invasive sleep
patterns as well as posture assessment that can lead to preventing ulcer development. The setup
was very complex, since placement of the IMUs were very precise and having a living subject
was noted to have its difficulties; however, having several methods of data collection can lead to
V. Conclusion
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Skin injuries, mainly pressure ulcers, are developed from increased loads of force from a
surface over a bony prominence for a discrete period of time. Pressure points can be analyzed
and identified through redistribution surfaces and various medical sensors. Identifying these
regions for infants benefit pediatric studies tremendously, leading to the prevention of skin
breakdown and recognizing potential discomforts in posture. In turn, these benefits also lead to
the effectiveness of pressure mattresses for infants, especially those with weaker skin integrity,
Works Cited:
[1] Allman, R. M., Goode, P. S., Burst, N., Bartolucci, A. A., Thomas, D. R. (1999). Pressure
ulcers, hospital complications, and disease severity: impact on hospital costs and length
of stay. Advances in Wound Care: The Journal for Prevention and Healing 12, 22-30.
[2] Arnold, John B. et al. “The Impact of Increasing Body Mass on Peak and Mean Plantar
Pressure in Asymptomatic Adult Subjects during Walking.” Diabetic Foot & Ankle 1
[3] “Body Pressure Measurement System (BPMS)”. Tekscan. 2018. Web. 14 April 2018.
<https://www.tekscan.com/products-solutions/systems/body-pressure-measurement-
system-bpms?tab=applications>.
[4] Curley, M. A. Q., Razmus, I. S., Roberts, K. E., & Wypij, D. J. (2003). “Predicting pressure
doi:10.1097/00006199200301000-00004.
[5] “International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in
2018. <http://www.woundsinternational.com/media/issues/300/files/content_8925.pdf>.
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[6] “Medical Sensor 5400N - Pressure Mapping, Force Measurement, and Tactile Sensors.”
sensors/5400n>.
[7] “Pressure Mapping for Test & Design”. Tekscan. 2018. Web. 10 April 2018.
<https://www.tekscan.com/product-group/test-measurement/pressure-mapping>.
[8] Razmus, I. S., Roberts, K. E., & Curley, M. A. Q. (2001). Pressure Ulcers in Critically
Ill Infants and Children Incidence and Associated Factors. Critical Care Medicine, 29
supp, A148
[9] Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers; A systematic review. JAMA.
2006;296:974-984. <rmatology/main03.htm.htm>.
<https://www.tekscan.com/products-solutions/software/research-software>.
[11] Rihar, Andraž et al. “Infant Trunk Posture and Arm Movement Assessment Using Pressure
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247204/>.
[12] Sharp, Catherine, and Mary-Louise McLaws. “A discourse on pressure ulcer physiology:
the implications of repositioning and staging.” World Wide Wounds. October 2005. Web.
Pressure-Ulcer-Physiology.html>.
[13] Shoemake, S., & Stoessel, K. (2007). Pressure ulcers in the surgical patient. Knowledge
<http://www.halyardhealth.com/media/1513/h0277-0701_ci_pressure_ulcer.pdf>.
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[14] Siddiqui et al. “A Continuous Bedside Pressure Mapping System for Prevention of Pressure
2013;25(12):333-339.
Citation of Figures:
[1] “International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in
2018. <http://www.woundsinternational.com/media/issues/300/files/content_8925.pdf>.
<https://www.tekscan.com/products-solutions/medical-sensors/5400n>.
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APPENDIX SECTION
These figures, provided on the IRB consent form for each participant, demonstrates the
appropriate measures taken to help assure calibration of the pressure sensor and for correlation
data. Each region of the figure (labeled A – I) is identified and given a short description of the
Measurement Regions:
(B) Stature – vertical distance from the surface to the subject’s head, with the subject facing
forward
(C) Acromial Shoulder Height – vertical distance from surface to the top of the subject’s
lateral shoulder area
(D) Waist Height – vertical distance from surface to the waist landmark
(E) Tibiale Height – vertical distance from the surface to the subject’s proximal medial
margin of the tibia (knee)
(F) Thumb-Tip Reach – horizontal distance from the subject’s back against the wall, to the
tip of their thumb when reaching straight out
(G) Shoulder-Elbow Length – distance from the top of the acromion process to the bottom
of the elbow; subject sits erect with the arms placed vertically and the hands extending
horizontally
(H) Forearm-Hand Length – using the same position as demonstrated in F, the distance
from the tip of the elbow to the tip of the longest finger of the hand
(I) Head Circumference – maximum circumference of head, above the brow ridges