Pediatric Burn Care: Unique Considerations in Management

The efficacy of therapeutic interventions on paediatric burn patients' height, weight, body composition, and muscle strength: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of therapeutic interventions on pediatric burn patients' height, weight, body composition, and muscle strength.

METHODS

A systematic literature search was conducted in PubMed, Embase, and Web of Science up to March 2021. Eligible interventional studies reported metrics on the height, weight, body composition, or muscle strength of pediatric burn patients in a peer-reviewed journal. Meta-analyses were performed if ≥ 2 trials of clinical homogeneity reported on an outcome measure at the same time point post-burn.

RESULTS

Twenty-six interventional studies were identified, including twenty-two randomised controlled trials and four non-randomised trials. Most studies were conducted by a single institution. On average, the burn covered 45.3% ( ± 9.9) of the total body surface area. Three categories of interventions could be distinguished: rehabilitative exercise programs, pharmacologic agents, and nutrition support.

CONCLUSIONS

Each of the interventions had a positive effect on height, weight, body composition, or muscle strength. The decision to initiate an intervention should be made on a case-by-case basis following careful consideration of the benefits and risks. In future research, it is important to evaluate the heterogeneity of intervention effects and whether participation in an intervention allowed pediatric burn patients to reach the physical and functional status of healthy peers.

Pediatric Burns: From Acute Care Through Reconstruction in 2024

Children are disproportionately affected by burn injuries. Differences between adult and pediatric burns range from epidemiologic characteristics to pathophysiological considerations, which vary between different age subgroups. All these factors must be considered in each phase of burn care. This article reviews the most important aspects of the management of a pediatric burned patient starting from the acute through reconstructive phases.

Epidemiology and first aid measures in pediatric burn patients in northern China during 2016-2020: A single-center retrospective study

Background and Aims

Burn and scald injuries are the fourth most common type of trauma. Pediatric burns account for a high proportion of the total number of burn patients and impose a high burden on public health. Understanding the epidemiology of pediatric burns can help improve science education and reduce the incidence of burn injuries.

Methods

This study is a single-center retrospective study. One thousand five hundred and twenty-seven pediatric burn patients admitted to our burn center from January 2016 to December 2020 were included. Demographic and epidemiological data of included patients were extracted and analyzed. The correlations of categorical data were tested by the Chi-square tests, and differences of continuous data were tested by the Kruskal-Wallis tests. A p-value of less than 0.05 was considered to be statistically significant.

Results

The results showed that children under 3 years of age were most susceptible to burn and scald injuries. Burn injuries were most likely to occur in the season of winter and at the place of home. 56.6% of included patients did receive first aid measures, while 1.8% received gold-standard first aid. Clinical variables related to the severity of injuries were statistically different between patients with and without cooling measures in first aid. Linear regression models showed that emergency treatment of burns in children and adolescents was associated with outcome indicators, including number of operations, total operation duration per total burn surface area (TBSA), cost per TBSA, and length of stay per TBSA.

Conclusions

This study summarized the epidemiology and outcomes of pediatric burn patients admitted to a burn center in northern China. Adopting cooling measures in first aid can reduce the severity of injuries and reduce the burden on the medical system. Education on burn prevention and first aid measures to caregivers of children, especially preschool children, should be strengthened.

Minority pediatric burn survivors undergo more burn operations: A single center's five-year experience

Burn injuries remain a significant source of trauma in the United States and disproportionately affect racial and ethnic minorities. Although disparities are well documented in adults, less is known regarding those in pediatric populations. To address this gap in literature, we aim to better characterize burn injuries, inpatient treatments, and post-discharge outcomes in minority pediatric burn patients. We hypothesize minority patients undergo more surgery and re-admissions than non-minority patients for burn care. This is a single institution retrospective chart review of pediatric patient admissions with burn injuries from July 1st, 2016 to July 1st, 2021. Demographics, details of injury, inpatient surgical and non-surgical care, and post-discharge outcomes were collected. Patients identifying as Hispanic/Latino, Black, and Asian were coded as minority patients. Univariate analysis was utilized. A total of 332 patients with average age of 4.9 years (SD: 4.4) and average total burn surface area (TBSA) of 8.5% (SD: 10.0) were collected. Minority patients were significantly more likely to experience accidental burn injury (p < 0.01), inhalational injury (p < 0.01), surgical management (p < 0.01), and to undergo skin graft (p < 0.01) than White patients. Minority patients were significantly more likely to undergo laser treatment after discharge (p < 0.01) than White patients. Our study shows minority pediatric patients are at risk for non-intentional burn injuries that undergo surgical management such as skin grafting and longitudinal reconstructive procedures including laser therapy more often. Short-term goals should include facilitating improved physical and psychosocial outcomes in this often-underserved patient population.

Pharmacologic Management of Pediatric Burns

Many pediatric patients with burn injuries may be initially treated in a hospital where pediatric specialized care, including resources and trained personnel may be limited. This includes resuscitation in adult emergency departments and inpatient care in mixed adult-pediatric burn units. The intent of this review is to provide a compilation of topics for the adult trained pharmacist or another healthcare practitioner on the management of pediatric patients with burn injuries. This article focuses on several key areas of pharmacologic burn management in the pediatric patient that may differ from the adult patient, including pain and sedation, fluid resuscitation, nutrition support, antimicrobial selection, anticoagulation, and inhalation injury. It is important that all clinicians have resources to help optimize the management of burn injuries in the pediatric population as, in addition to burn injury itself, pediatric patients have different pharmacokinetics and pharmacodynamics affecting which medications are used and how they are dosed. This article highlights several key differences between pediatric and adult patients, providing an additional resource to assist adult-trained pharmacists or other healthcare practitioners with making clinical decisions in the pediatric burn population.

Staphylococcal Infections and Neonatal Skin: Data from Literature and Suggestions for the Clinical Management from Four Challenging Patients

Staphylococcal infections in neonates might be associated with skin blistering since early antibiotic therapy has been shown to limit infection spread and positively influence outcomes; therefore, neonatologists should be aware of these conditions. This review examines the recent literature on the management of Staphylococcal infections that involve neonatal skin, discussing the most appropriate clinical approach to four cases of neonatal blistering diseases with Staphylococcal infections: a case of Staphylococcal bullous impetigo, a case of Staphylococcal scalded skin syndrome (SSSS), a case of epidermolysis bullosa with overlapping Staphylococcal infection, and a case of burns with overlapping Staphylococcal infection. In treating Staphylococcal infections involving skin in neonates, the presence or absence of systemic symptoms should be considered. In the lack of evidence-based guidelines in this age category, treatment should be individualized according to several factors including the extension of the disease or further skin comorbidities (such as skin fragility), with a multidisciplinary approach.

Effects of Aerobic Exercise in the Intensive Care Unit on Patient-Reported Physical Function and Mental Health Outcomes in Severely Burned Children-A Multicenter Prospective Randomized Trial

Severe burns are life-altering and can have lasting effects on patients' physical and mental health. Alterations in physical function, changes in appearance, and psychological disturbances resulting from severe burns are especially concerning in children, as they are still in the early stages of identity formation. Exercise in the nonburn population has been shown to improve quality of life and result in better physical and mental status. However, the effect of early exercise on the quality of life in pediatric burn patients requires more research.

METHODS

Forty-eight children between the ages of seven and seventeen with ≥30% total body surface area (TBSA) burn were randomized in a 1:2 fashion to receive treatment with standard-of-care (SOC) or standard-of-care plus exercise (SOC+Ex). Surveys administered at admission and discharge collected patient-reported information regarding physical and mental health outcomes. The results are given as means +/- standard deviation. Significance was set at p < 0.05.

RESULTS

The average age of the SOC and SOC+Ex groups were 12 ± 3 and 13 ± 4 years, respectively. The average %TBSA burned in the SOC and SOC+Ex groups were 54 ± 17 and 48 ± 14, respectively. The SOC+Ex group averaged 10 ± 9 exercise sessions (range of 1 to 38 sessions) with an attendance rate of 25% (10 sessions out of 40 BICU days). Both groups demonstrated significant improvement in patient-reported physical and mental outcomes during hospital admission (p < 0.05) However, additional exercise did not exhibit any additional benefits for measured levels.

CONCLUSIONS

Our recommendation is for all pediatric patients in the BICU to continue with the SOC and consult with their physician over the benefits of additional aerobic exercise. This study suggests that perhaps there is potential for increasing the amount of exercise that can be administered to pediatric burn survivors beyond SOC as we did not find aerobic exercise to be of any harm to any patients if it is performed properly and under supervision.

Management of Pediatric Facial Burns with Zinc-Hyaluronan Gel

Zinc-hyaluronan-containing burn dressings have been associated with enhanced reepithelialization and low infection rates, although their effectiveness has not yet been investigated in pediatric facial thermal injuries. This single-arm, retrospective cohort study assessed the characteristics of 23 children (≤17-year-old) with facial superficial partial-thickness burns and the wound closure capabilities of the applied zinc-hyaluronan gel. Patients were admitted consecutively to the Pediatric Surgery Division in Pécs, Hungary, between 1 January 2016 and 15 October 2021. The mean age of the children was 6.2 years; 30.4% of them were younger than 1 year. An average of 3% total body surface was injured in the facial region and 47.8% of the patients had other areas damaged as well, most frequently the left upper limb (30.4%). The mean time until complete reepithelialization was 7.9 days and the children spent 2 days in the hospital. Wound cultures revealed normal bacterial growth in all cases and follow-up examinations found no hypertrophic scarring. In conclusion, pediatric facial superficial partial-thickness burns are prevalent during infancy and coincide with left upper limb injuries. Rapid wound closure and low complication rates are accountable for the moderate amount of hospitalization. These benefits, along with the gel’s ease of applicability and spontaneous separation, are linked to child-friendly burn care.

Epidemiological and Clinical Characteristics of 5,569 Pediatric Burns in Central China From 2013 to 2019

Background

Pediatric burns of all the ages are prevalent worldwide, posing a severe health risk to children. This study aims to examine pediatric burns' clinical characteristics and epidemiology in central China.

Methods

The pediatric patients of the Burn Research Center, Department of the First People's Hospital of Zhengzhou City from 2013 to 2019 were retrospectively studied and the relevant data were collected from the hospitalized medical records [e.g., demographic, etiology, length of stay (LOS), age, gender, burn area and depth, number of surgeries, cost, and outcome].

Results

A total of 5,569 pediatric burn patients were included, accounting for 43.9% of the total burn population. Electric burns represented a relatively small proportion (1.17%) but were more likely to lead to disabilities or death than scalds (90.63%) and flames (5.12%). The median age was 2 years [interquartile range (IQR): 1–4] and the boys/girls ratio ranged from 1.3:1 to 1.6:1. The most commonly burnt anatomic sites were the limbs (38.3%), with a median %TBSA (total body surface area) of 6 (IQR: 4–10). The complications of shock and pneumonia accounted for 7.6 and 19.2%, respectively. The peak months of pediatric burns included January, May, and August and the rural/urban ratio reached 1.61:1. The percentage of burn wounds treated surgically increased considerably from 2013 to 2019 (3.8 vs. 37.8%). The median hospital LOS was 15 days (IQR: 8–28 days), with the three high-risk factors (e.g., more surgeries, more %TBSA, full-thickness skin burns). The median cost of hospitalization was 1,511 USD (IQR: 848–2,648 USD) and the main risk factors consisted of full-thickness burns, more %TBSA, longer LOS, and more surgical procedures. Among all the patients, LA50 was 78.63% (95% CI = 75.12–83.45) and the overall mortality reached 0.1% since seven deaths were recorded.

Conclusion

Scalds, flames, contact, and chemicals are the main causes of burns among children aged 1–5 years in central China. Accordingly, various prevention strategies should be employed depending upon the cause of the burn.

Social Work Evaluations Among Pediatric Patients Transferred for Burn Care

Introduction

Regionalization efforts aim to improve healthcare by designating specialty centers for a geographic area. Regionalization may play a role in determining patient treatment plans and outcomes. We hypothesize that these factors may be influenced by race, socioeconomics, insurance, and longitudinal follow-up.

Methods

Retrospective review of 81 patients ages 0-18 years evaluated at our Level 2 Trauma Center between February 2016-December 2020 who met criteria for transfer to a Regional Burn Center.

Results

67% of patients were transferred to the Regional Burn Center. There was no difference in the percentage of transferred patients with respect to age, race, ethnicity, insurance type, or rurality of home address. Secondary analysis showed that 57.4% of children were transferred without evaluation by social work. Five patients’ injuries were due to non-accidental trauma (NAT); two of these patients were transferred without social work evaluations. 28% of those transferred had documented involvement of Child Protective Services (CPS). Of the 31 transferred patients without social work evaluation, 67% had incomplete or missing notes from the burn center, including 100% of those subsequently confirmed to be due to NAT. Only 32% of patients received follow-up at our institution.

Conclusion

We identified no differences in transfer percentages with respect to race, ethnicity, or insurance type. Secondary analysis demonstrated a significant gap in care regarding access to records and social work involvement. As NAT and social concerns are common amongst children with burns, we propose policies to ensure that these concerns are not overlooked during regionalization efforts.

Safety and benefits of intraoperative enteral nutrition in critically ill pediatric burn patients: A systematic review and pooled analysis

Burn injuries significantly increase a patient's metabolic demand. Adequate nutrition is essential as an adjunct to recovery and reducing morbidity and mortality. In contrast to adults, this is especially important for pediatric patients who have limited reserves and are in a period of growth. Burn patients often require multiple anesthetic procedures that are accompanied by standard perioperative fasting periods that result in substantial nutritional interruptions. Continuous intraoperative feeding has been proposed as a solution, but there is no current consensus on its role and safety, particularly in the pediatric population. Thus, the goal of this study was to examine the safety and benefits of intraoperative nutrition in critically-ill pediatric burn injured patients. A systematic review of MEDLINE, PubMed, Scopus, and Web of Science was conducted using the following terms: feeding or enteral or nutrition or fasting and adolescent or youth or pediatric or child or teen and burn or thermal injury or fire. The primary outcome was incidence of aspiration. Secondary outcomes included patient nutritional status (caloric deficit and weight), wound healing, days spent in the intensive care unit, ventilator days, pneumonia, number of surgeries, length of hospital stay, and mortality. Pooled analyses of binary outcomes were computed. Four studies consisting of 496 patients, met inclusion criteria. All studies were level IV evidence, but had high methodological quality. The median burn total body surface area (TBSA) was 43.8% (IQR 33.4-58.8%), with a median of 30% of patients having an inhalational injury. Patients underwent a median of 4.2 surgeries (IQR 1.8-7.4). Intraoperative feeding was conducted through nasoduodenal tubes. There were no aspiration events. Pooled analysis demonstrated that there were no differences in rates of aspiration, pneumonia, or wound infection (p>0.05) between patients who were intraoperatively fed and those who were not. Those fed intraoperatively had significantly more surgeries, ventilator days, longer hospital stays, but lower mortality (p<0.05). There was large heterogeneity in nutritional assessment methods. Intraoperatively fed patients had an average gain of 144.4 kcal/kg,1.7 days of exclusive enteral nutrition (vs. loss of -119.1 kcal/kg and -1.4 days), and a cumulative positive caloric balance of +2673kcal ±2147 (vs. loss of -7899kcal ±3123) compared to those with interrupted feeding. Continuous intraoperative duodenal feeding during burn surgery appears to be safe in the pediatric burn population, with no reported episodes of aspiration. Uninterrupted feeding was also associated with weight maintenance and reduced caloric deficit. It may also have a survival benefit, as continuously fed patients needed more surgeries and intensive/hospital care, but had decreased mortality.

Türkiye Güneydoğu Anadolu bölgesinde pediatrik yanık vakalarının analizi:10 yıllık retrospektif çalışma

Background: Burns continue to be a serious global public health problem all over the world, especially in developing countries. Materials and Methods: The age, gender, cause of injury, and total body surface area (TBSA) of the burn, complications, and mortality rate of 1,038 patients who were hospitalized in our burn center between January 1, 2010, and January 1, 2020, were analyzed. Results: The burned surface area was greater in boys than in girls. The mean burned body surface area for all patients was 9.2 ± 6.35, and the mortality rate was 1.45%. Hot liquids, such as tea, hot milk, hot water, and oily food, were the causes of burns in 84.7% of the patients. Hot objects, hot melted nylon, hot tandoor and embers, and hot asphalt accounted for 7.7% of the burns. Moreover, flame burns, electrical burns and frostbite, and other burn causes accounted for 5.6%, 1.2 %, and 0.8% of burn injuries, respectively. Conclusions: In our region, pediatric burns occurred mostly in boys under the age of three and in children whose parents had low educational levels living in rural areas. We believe that the burn prevention program should be adjusted according to these results.

Development of a Unified National Database of Burn Centers with Co-located Emergency Departments, 2020

The care of severely burned patients comes with unique requirements for specialized burn centers. The American Burn Association sets guidelines for burn centers and provides a voluntary program to verify their quality of care. However, not all burn centers are verified, and it is unclear which nonverified centers have met requirements set by their state health departments. To compile a complete database of all United States emergency departments in facilities with confirmed burn centers, we investigated state requirements to supplement data from the American Burn Association verification process. In 2020, only 13 states set requirements for burn centers; 3 states explicitly required American Burn Association verification, 4 used modified American Burn Association criteria, and 6 used alternate criteria. Only 2 states had separate requirements for pediatric burn centers. Based on adherence to state and American Burn Association criteria, we identified 90 confirmed burn centers in 2020, 85 of which had emergency departments. Of these 85, 45 (53%) were only verified, 17 (20%) were only state-confirmed, and 23 (27%) were both. Emergency departments in a confirmed burn center were more likely-than those without-to have higher adult and pediatric visit volumes, be academic, be a stroke or trauma (adult or pediatric) center, have a dedicated pediatric area, and have a pediatric emergency care coordinator. We compiled the first unified burn center database that incorporates state and American Burn Association lists. This database can be utilized in future health services research and is available to the public through a smartphone application.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Using Social Media for the Prevention of Pediatric Burn Injuries: Pilot Design and Usability Study

BACKGROUND

Most pediatric burn injuries are preventable. Social media is an effective method for delivering large-scale messaging and may be useful for injury prevention in this domain.

OBJECTIVE

This study evaluates the feasibility of creating a social media campaign for pediatric burn injury prevention.

METHODS

Ad spots containing a headline, short introduction, and video were created and posted on Facebook and Instagram over 4 months. Ad spots were targeted to parents and caregivers of children in our region with the highest number of burn injuries. We assessed the impact of each ad set using ThruPlays, reach, and video plays.

RESULTS

We created 55 ad spots, with an average length of 24.1 (range 10-44) seconds. We reached 26,496 people during the campaign. The total ThruPlays of the 55 ad spots were 14,460 at US $0.19 per ThruPlay. Ad spots related to home safety had a significantly higher daily ThruPlay rate than those related to fire safety (6.5 vs 0.5 per day; P<.001).

CONCLUSIONS

Social media is a feasible modality for delivering public health messages focused on preventing pediatric burn injuries. Engagement with these ads is influenced by ad presentation and the focus of the underlying injury prevention message.

Diverse Treatments for Deep Burn Wounds: A Case Report

ABSTRACT

Patients with extensive deep burns usually experience infections and organ dysfunction. Proactive and effective wound repair is key to treatment. If large wounds remain open, systemic infection and multiple organ dysfunction syndrome can occur, threatening the lives of patients. Current wound repair methods include skin grafts, flap repair, negative-pressure wound therapy, and cellular and/or tissue-based products. For deep, complex burn wounds, a single form of treatment is usually ineffective. This article reports a rare case of burn wound repair. The patient was burned by a charcoal flame on multiple parts of his body after carbon monoxide poisoning. Pneumothorax and acute renal failure occurred after the injury, accompanied by multiple osteonecroses of the trunk and lower limbs. A multidisciplinary team formulated an individualized treatment plan; the diverse treatments included closed chest drainage, continuous renal replacement therapy, infection control, analgesia, wound debridement, negative-pressure wound therapy, cellular and/or tissue-based products, autologous dermal scaffold graft, skin grafts, flap transposition, platelet-rich plasma, and rehabilitation, which ultimately saved the patient's life and led to healing of all the wounds.

Factors Associated with Pediatric Burn Clinic Follow-up after Emergency Department Discharge

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within one week. A total of 196 patients (Mage=5.5 years; 54% male) were included in analyses. Average percent total body surface area was 1.9 (SD=1.5%). One-third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (OR=1.00; 95% CI: [.99-1.00], p=.045), patients with superficial burns (OR=9.37; 95% CI: [2.50-35.16], p=.001), patients with smaller percent total body surface area (OR=1.37; 95% CI: [1.07-1.76], p=.014), and patients with Medicaid insurance (OR=.22; 95% CI: [.09-.57], p=.002) or uninsured/unknown insurance (OR=.07; 95% CI: [.02-.26], p=.000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Variation in acute fluid resuscitation among pediatric burn centers

BACKGROUND

Accurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates.

METHODS

Five pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received.

RESULTS

Differences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers' resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001).

CONCLUSIONS

This variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.

Pediatric enteral nutrition therapy for burn victims: when should it be initiated?

Objective

To review the scientific evidence regarding the initiation of enteral nutrition in the pediatric burn population.

Methods

This study was a systematic review and meta-analysis of randomized clinical trials comparing early enteral nutrition and late enteral nutrition in individuals aged 1 month to 18 years with burns. The MEDLINE/PubMed, Embase and Cochrane Library databases were searched using the terms "burns", "fires", "child nutrition disorders", "nutritional support" and related terms.

Results

Three articles that included a total of 781 patients were identified. There was no significant difference in the mortality rate between the early and late groups (OR = 0.72, 95%CI = 0.46 - 1.15, p = 0.17). Patients who received early enteral nutrition had a 3.69-day reduction in the length of hospital stay (mean difference = -3.69, 95%CI = -4.11 - -3.27, p < 0.00001). There was a higher incidence of diarrhea and vomiting and decreased intestinal permeability in the early group. This group also presented higher a serum insulin concentration and insulin/glucagon ratio as well as lower caloric deficit and weight loss when compared to the control group.

Conclusion

Analysis of the different intragroup variables suggests the importance of starting nutritional support early. Considering the number of pediatric burn patients, there is a need for robust studies with greater scientific impact.

Characteristics and outcome of burned children admitted to a pediatric intensive care unit

Objective

To analyze the characteristics and outcomes of children hospitalized for burns in a pediatric trauma intensive care unit for burn patients.

Methods

An observational study was conducted through the retrospective analysis of children (< 16 years) admitted to the pediatric trauma intensive care unit for burn victims between January 2013 and December 2015. Sociodemographic and clinical variables were analyzed including the causal agent, burned body surface, presence of inhalation injury, length of hospital stay and mortality.

Results

The study analyzed a sum of 140 patients; 61.8% were male, with a median age of 24 months and an overall mortality of 5%. The main cause of burns was scalding (51.4%), followed by accidents involving fire (38.6%) and electric shock (6.4%). Mechanical ventilation was used in 20.7% of the cases. Associated inhalation injury presented a relative risk of 6.1 (3.5 - 10.7) of needing ventilatory support and a relative risk of mortality of 14.1 (2.9 - 68.3) compared to patients without this associated injury. A significant connection was found between burned body surface and mortality (p < 0.002), reaching 80% in patients with a burned area greater than 50%. Patients who died had a significantly higher Tobiasen Abbreviated Burn Severity Index than survivors (9.6 ± 2.2 versus 4.4 ± 1.1; p < 0.001). A Tobiasen Abbreviated Burn Severity Index ≥ 7 represented a relative risk of death of 68.4 (95%CI 9.1 - 513.5).

Conclusion

Scalding burns are quite frequent and are associated with high morbidity. Mortality is associated with the amount of burned body surface and the presence of inhalation injury. Special emphasis should be given to accidents involving fire, reinforcing proper diagnosis and treatment of inhalation injury.

Emergency department resuscitation of pediatric trauma patients in Iraq and Afghanistan

BACKGROUND

Military hospital healthcare providers treated children during the recent conflicts in Afghanistan and Iraq. Compared to adults, pediatric patients present unique challenges during trauma resuscitations and have notably been discussed in few research reports. We seek to describe ED interventions performed on pediatric trauma patients in Iraq and Afghanistan.

METHODS

We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped based on Centers for Disease Control age categories. We used descriptive statistics.

RESULTS

During this period, there were 3388 pediatric encounters that arrived at the ED with signs of life or on-going interventions. Most subjects were male (77.2%), located in Afghanistan (67.9%), injured by explosive (43.2%), and admitted to an intensive care unit (57.8%). Most of those arriving to the ED alive or with on-going interventions survived to hospital discharge (91.6%). The most frequently encountered age group was 5-9years (33.3%) followed by 10-14years (31.5%). The most common interventions were vascular access (86.6%), fluid administration (85.0%), and external warming (44.6%). Intubation was the most frequent airway intervention (18.2%). Packed red blood cells were the most frequently administered blood product (33.8% of subjects).

CONCLUSIONS

Pediatric subjects accounted for a notable portion of care delivered in theater emergency departments during the study period. Vascular access and fluid administration were the most frequently performed interventions. Pediatric-specific training is needed as a part of deployment medicine operations.

Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects

Burn injuries are a devastating critical care problem. In children, burns continue to be a major epidemiologic problem around the globe resulting in significant morbidity and death. Apparently, treating these burn injuries in children and adults remains similar, but there are significant physiological and psychological differences. The dermal layer of the skin is generally thinner in neonates, infants, and children than in adults. Enhanced evaporative loss and need for isotonic fluids increases the risk of hypothermia in the pediatric population. The pain management of the children with major burns challenges the skills of the personnel of every unit. Managing these wounds requires intensive therapeutic treatment for multi-organ dysfunction, and surgical treatment to prevent sepsis and other complications that further delay wound closure. Alternatives to the practice of donor site harvest and autografting for the treatment of severe burns and other complex skin defects are urgently needed for both adult and pediatric populations. This review article focuses on thermal burn pathophysiology and pain management and provides an overview of currently approved products used for the treatment of pediatric burn wounds. A new promising approach has been presented as a first-line therapy in the treatment of burns to reduce surgical autografting in pediatric patients.