Special considerations in paediatric burn patients

Assessing Pediatric Burn Wound Infection Using a Point-of-Care Fluorescence Imaging Device

Wound infection is the most common complication among pediatric burn patients. When not treated promptly, burn wound infection may lead to delayed healing, failure of skin grafts, or death. Standard burn wound assessment includes inspection for visual signs and symptoms of infection (VSSI) and microbial sampling. To aid in the assessment of burn wound infection, the MolecuLight, a point-of-care autofluorescence imaging device, was introduced at our pediatric burn program in 2020. The MolecuLight uses violet light to illuminate the wound bed, causing clinically relevant quantities of 29 different species of bacteria (>104 CFU/g) to fluoresce in real time. The objectives of this study were to evaluate the role of the MolecuLight in the management of pediatric burn wounds and determine if the findings from the MolecuLight corresponded to VSSI and/or microbial sampling. A retrospective review of patients 0-18 years who had burn wounds assessed with the MolecuLight between November 1, 2020 and June 8, 2023 was conducted. Data were extracted from the medical records of 178 eligible patients with 218 wounds imaged with the device. Fluorescence corresponded with VSSI in 81% of wounds and microbial findings in 82% of wounds. MolecuLight fluorescence, in combination with VSSI, improved sensitivity for detecting wound infections by 39% and decreased specificity by 19% compared to visual signs and symptoms in isolation. Incorporation of the MolecuLight in standard burn wound assessments can improve the detection of infections, which may promote improved wound healing outcomes and antimicrobial stewardship.

Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury

INTRODUCTION

Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children.

METHODS

We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay.

RESULTS

2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56).

CONCLUSION

Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns.

TYPE OF STUDY

Retrospective study LEVEL OF EVIDENCE: Level III.

Efficacy and safety of recombinant human granulocyte-macrophage colony-stimulating factor hydrogel in treating second- or third-degree burn wounds in children: a systematic review and meta-analysis

Background

The efficacy and safety of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) hydrogel in adults with deep partial-thickness burns have been confirmed. However, the clinical safety and efficacy analysis of rhGM-CSF in pediatrics is lacking, and the results are questionable. Therefore, a meta-analysis was conducted to evaluate the efficacy and safety of rhGM-CSF hydrogel in children with second- or third-degree burn injury to provide evidence-based medicine for clinical application.

Methods

Articles on rhGM-CSF hydrogel for the treatment of pediatric burn wounds were retrieved from PubMed, Embase, WOS, Cochrane Central Registry of Controlled Trials, Chinese Biomedical Literature Database (CBM), China Science and Technology Journal Database (CSTJ), China National Knowledge Infrastructure (CNKI) and Wanfang from the inception of the databases to March 2024. Two reviewers screened articles and extracted the following data: general characteristics, intervention and treatment course, outcome measure. The meta-analysis was conducted using Revman 5.4 software.

Results

Eight reports (336 patients: experimental 175, control 161) were ultimately included in the meta-analysis, which showed that the experimental group (rhGM-CSF hydrogel ± other therapy) was superior to the control group (treatments without rhGM-CSF hydrogel) in terms of the wound healing rates at day 7 [mean difference (MD) =13.63, 95% confidence interval (CI): 7.25 to 20.00, P<0.001], day 14 (MD =15.59, 95% CI: 12.50 to 18.69, P<0.001), and day 21 (MD =7.47, 95% CI: 7.36 to 7.58, P<0.001), and the wound healing time (MD =-3.10, 95% CI: -3.50 to -2.71, P<0.001), and the differences were statistically significant. For the risks of bias, one study had a "high risk" in allocation sequence concealment, and the others were classified as "low risk" and "unclear risk".

Conclusions

rhGM-CSF hydrogel is significantly effective in improving the wound healing rate and shortening the wound healing time in children with second- or third-degree burns.

Epidemiology and early bacterial colonization of minor and moderate pediatric burns: A retrospective study from a developing country

OBJECTIVES

Infection is still the leading cause of morbidity and mortality among burn patients worldwide. Isolation and identification of pediatric burn wound bacterial colonizers can prevent infection and improve burn trauma treatment. In this study, we explored early microbial colonizers within the burn wounds and the susceptibility of those isolates to antibiotics among hospitalized pediatric patients with minor and moderate burns, clinically significant infections and outcomes.

METHODS

A retrospective analysis of pediatric patients admitted to the inpatient pediatric surgical ward and treated for minor and moderate burns from 2009 to 2018 was performed.

RESULTS

One hundred six patients met the inclusion criteria. The mean age was 3.6 ± three years (0.2-14.1 years). The most common type of burn was scald burns (82.1%). The mean TBSA of the hospitalized pediatric burn cases was 8.5% (IQR, 6-12%). Seventy-nine (74.5%) patients had positive wound cultures at admission, regardless of the hospital admission day. Fifty-eight (73.4%) had one bacterial growth (mono isolate), while 21 (26.6%) had mixed growth or poly isolates. Among patients with mixed growth or poly isolate, 16 had two bacteria, three had three bacteria, and one had four bacteria isolated, totaling 105 isolated microorganisms (14 different species, 70.5% Gram-positive bacteria and 29.5% Gram-negative bacteria). Twelve patients (11%) developed clinically significant infections (eleven got burn wound infection, and one had septicemia). All patients received prophylactic systemic antibiotics. Only 35.2% of the isolated bacteria from the wounds were sensitive to the prophylactic antibiotics, and only ∼17% in case of clinically significant infections. We found a statistically significant difference in the length of hospital stay between patients with initially colonized samples of burn wounds compared with patients with initial negative samples (p = 0.008). All patients in the cohort survived hospital discharge.

CONCLUSION

Despite common bacterial colonization of acute burn wounds, only ∼10% of the patients developed clinically significant infections, a minority of which were sensitive to prophylactic antibiotics. Our findings indicate the need to refine the antibiotic approach in pediatric patients with minor/moderate burns in our local setting.

Investigating the impact of COVID-19 on the provision of pediatric burn care

The COVID-19 pandemic had widespread effects on the healthcare system due to public health regulations and restrictions. The following study shares trends observed during these extraordinary circumstances to investigate the impact of the COVID-19 pandemic on the provision of pediatric burn care at an American-Burn-Association verified tertiary pediatric hospital in Ontario, Canada. Pediatric burn patient data for new burn patients between March 17th, 2019, and March 17th, 2021, was retrospectively extracted and two cohorts of patients were formed: pre-pandemic and pandemic, through which statistical analysis was performed. No significant changes in the number of admitted patients, age, and sex of patients were observed. However, a significant increase in fire/flame burns was observed during the pandemic period. Additionally, a decrease in follow-up care was observed while an increase in acute burn care (wound care and surgical interventions) was found for the pandemic cohort. Despite changes to hospital care facilities to maximize resources for COVID-19-related care, our findings demonstrate that burn care remained an essential service and significant reductions in patient volumes were not observed. Overall, this study will aid in future planning and management for the provision of pediatric burn resources during similar public health emergencies.

Influence of scar age, laser type and laser treatment intervals on paediatric burn scars: a systematic review and meta-analysis

Background

Laser therapy has emerged to play a valuable role in the treatment of paediatric burn scars; however, there is heterogeneity in the literature, particularly concerning optimal timing for initiation of laser therapy. This study aims to investigate the effect of factors such as scar age, type of laser and laser treatment interval on burn scar outcomes in children by meta-analysis of previous studies.

Methods

A literature search was conducted across seven databases in May 2022 to understand the effects of laser therapy on burn scar outcomes in paediatric patients by metanalysis of standardized mean difference (SMD) between pre- and post-laser intervention. Meta-analyses were performed using the Comprehensive Meta-Analysis software version 4.0. Fixed models were selected when there was no significant heterogeneity, and the random effects model was selected for analysis when significant heterogeneity was identified. For all analyses, a p-value < 0.05 was considered significant.

Results

Seven studies were included in the meta-analysis with a total of 467 patients. Laser therapy significantly improved Vancouver Scar Scale (VSS)/Total Patient and Observer Scar Assessment Scale (Total POSAS), vascularity, pliability, pigmentation and scar height of burn scars. Significant heterogeneity was found between the studies and thus subgroup analyses were performed. Early laser therapy (<12 months post-injury) significantly improved VSS/POSAS scores compared to latent therapy (>12 months post-injury) {SMD -1.97 [95% confidence interval (CI) = -3.08; -0.87], p < 0.001 vs -0.59 [95%CI = -1.10; -0.07], p = 0.03} as well as vascularity {SMD -3.95 [95%CI = -4.38; -3.53], p < 0.001 vs -0.48 [95%CI = -0.66; -0.30], p < 0.001}. Non-ablative laser was most effective, significantly reducing VSS/POSAS, vascularity, pliability and scar height outcomes compared to ablative, pulse dye laser and a combination of ablative and pulse dye laser. Shorter treatment intervals of <4 weeks significantly reduced VSS/POSAS and scar height outcomes compared to intervals of 4 to 6 weeks.

Conclusions

Efficacy of laser therapy in the paediatric population is influenced by scar age, type of laser and interval between laser therapy application. The result of this study particularly challenges the currently accepted initiation time for laser treatment. Significant heterogeneity was observed within the studies, which suggests the need to explore other confounding factors influencing burn scar outcomes after laser therapy.

Assessment of Small Paediatric Burns: A Coin-Based System

A review of paediatric burns in our burns facility in the United Kingdom demonstrated variable accuracy of size, and a majority documented as <1% total body surface area (TBSA). Accurate assessment is important for medical records, clinical management and non-accidental injuries. We propose to assess burn size with a coin-based system, where small burns are described by single/multiple sterling coins. Participants were asked about their confidence in evaluating small paediatric burns. Participants were given ten scenarios which included photographs of paediatric patients with small burns. They were asked to assess burn size in their normal manner (TBSA, measurement) and with a coin-based system. The 'burns' were drawn on children based on a given coin size and percentage so that the accuracy of the participant's answer was quantifiable. Participants provided qualitative feedback in a questionnaire on the coin-based system. Thirty nurses and medical staff of varying seniority actively involved in referral/management of paediatric burns took part, creating over 300 responses. In preliminary questions, 66% of participants did not feel confident in estimating paediatric burns and 83% needed to refer to a paediatric burns chart. Accuracy of burn size using TBSA and the coin-based system was 45% and 67%, respectively. The majority (97%) stated estimating size was easier, and 93% found it more accurate. A total of 87% found communication between colleagues easier. Results highlight the improved assessment of small burns in our hospital using a coin-based approach in comparison to TBSA, and could facilitate accurate communication between health care professionals.

Special Considerations for Pediatric Burn Injuries

Burns are the fifth leading cause of non-fatal childhood injuries. Physiological differences between children and adults lead to unique considerations when treating young burn survivors. In addition to the physical and psychological concerns which must be considered in adult burn rehabilitation, pediatric burn rehabilitation must also consider the developmental stage of the child, preexisting developmental delays, and the impact of scaring on growth and motor skill attainment. Treatment of pediatric burn survivors requires a multidisciplinary approach centered around caring for not only the child but also for their parents, siblings, and other caregivers. For children who sustain burns early in life, long-term follow-up is essential and should be conducted under the guidance of a burn center for the early identification of needed interventions during periods of growth and development. This article considers pediatric-specific factors, which may present during the rehabilitation of a child with a burn injury.

Influence of scar age, laser type and laser treatment intervals on adult burn scars: A systematic review and meta-analysis

AIM

The study aims to identify whether factors such as time to initiation of laser therapy following scar formation, type of laser used, laser treatment interval and presence of complications influence burn scar outcomes in adults, by meta-analysis of previous studies.

METHODS

A literature search was conducted in May 2022 in seven databases to select studies on the effects of laser therapy in adult hypertrophic burn scars. The study protocol was registered with PROSPERO (CRD42022347836).

RESULTS

Eleven studies were included in the meta-analysis, with a total of 491 patients. Laser therapy significantly improved overall VSS/POSAS, vascularity, pliability, pigmentation and scar height of burn scars. Vascularity improvement was greater when laser therapy was performed >12 months (-1.50 [95%CI = -2.58;-0.42], p = 0.01) compared to <12 months after injury (-0.39 [95%CI = -0.68; -0.10], p = 0.01), the same was true for scar height ((-1.36 [95%CI = -2.07; -0.66], p<0.001) vs (-0.56 [95%CI = -0.70; -0.42], p<0.001)). Pulse dye laser (-4.35 [95%CI = -6.83; -1.86], p<0.001) gave a greater reduction in VSS/POSAS scores compared to non-ablative (-1.52 [95%CI = -2.24; -0.83], p<0.001) and ablative lasers (-0.95 [95%CI = -1.31; -0.59], p<0.001).

CONCLUSION

Efficacy of laser therapy is influenced by the time lapse after injury, the type of laser used and the interval between laser treatments. Significant heterogeneity was observed among studies, suggesting the need to explore other factors that may affect scar outcomes.

Web-based E-survey in identifying current physiotherapy practices in paediatric burns

INTRODUCTION

Physiotherapy practices in pediatric burns involves relaxation techniques and exercise training for attaining physical fitness, improving quality of life and, thereby to prevent primary and secondary complications. Physical activity and exercise act as a meaningful and purposeful tool for attaining physical fitness after burn injury.

AIM

The aim of this e-survey is to identify the current practices of physiotherapy interventions in pediatric burn rehabilitation among physiotherapy students and professionals.

METHODS

The e-survey was created with validated questionnaire using a Google Forms to gather the information related to current physiotherapy practices in pediatric burns. After the sample size estimation, survey link were sent to identified 144 physiotherapy students and professionals using social networking sites which includes, WhatsApp, Facebook and Instagram for this cross-sectional e-survey. The frequency and percentage of survey responses were analyzed.

RESULTS

Among 144 identified participants, 62 participants completed the survey, resulting in the response rate of (43.0%). The findings of this study revealed that> 50% of physiotherapy students, and professionals, are performing pain and scar assessment, along with their regular physiotherapy management in children with burns. In addition to these, they also practice physiotherapy for burn conditions in pediatric intensive care units (PICU), pediatric wards, and clinical outpatient department (OPD) settings.

CONCLUSION

Physiotherapy students and professionals have sufficient knowledge regarding pediatric burns complications, and also, they are well aware regarding recent physiotherapy practices in pediatric burn care management.

Public perception of household risks for pediatric burn injuries and assessment of management readiness

INTRODUCTION

Children are uniquely vulnerable to injury because of near-complete dependence on caregivers. Unintentional injury is leading cause of death in children under the age of 14. Burns are one of the leading causes of accidental and preventable household injuries, with scald burns most common in younger children and flame burns in older ones. Education is a key tool to address burn prevention, but unfortunately these injuries persist. Critically, there is a paucity of literature investigating adult comprehension with respect to potential risks of household burns. To date, no study has been performed to assess management readiness for these types of injuries without seeking medical care.

METHODS

Qualtrics™ surveys were distributed to laypersons via Amazon Mechanical Turk. Demographics were self-reported. The survey was divided into two parts, management knowledge, and risk identification. The management part involved a photograph of a first-degree pediatric burn injury and required identification of the degree of injury and three potential initial managements. The risk-identification section required correctly identifying the most common mechanisms of burn injury for different age groups followed by general identification of 20 household burn risks. Survey responses were analyzed using two-tailed Student's t-tests and chi-square analyses, univariate and multivariate analysis, and linear regression.

RESULTS

Of the 467 respondents, the mean age was 36.57 years, and was 59.7% (279) male. Only 3.2% of respondents were able to correctly identify all 20 potential risks listed in our survey. Additionally, only 4.5% of respondents correctly identified all three appropriate initial management options (cool water, sterile gauze, and over-the-counter analgesics) without misidentifying incorrect options. However, 56.1% of respondents were able to select at least one correct management option. For image-based injury classification, the most common response was incorrectly second-degree with 216 responses (42.2%) and the second-most common response was correctly first-degree with 146 responses (31.3%). Most respondents claimed they would not seek medical attention for the injury presented in the photograph (77.7%). When comparing the responses of individuals with children to those without, there were no statistically significant differences in ability to assess household risks for pediatric burns. For the entire population of respondents, the mean score for correctly identifying risks was 38%.

CONCLUSION

This study revealed a significant gap in public awareness of household risks for pediatric burns. Furthermore, while most individuals would not seek medical care for a first-degree pediatric burn injury, they were readily available to identify proper initial management methods. This gap in knowledge and understanding of household pediatric burn injuries should be addressed with increased burn injury prevention education initiatives and more parental counseling opportunities.

Race, area deprivation index, and access to surgical burn care in a pediatric population in North Carolina

BACKGROUND

Burns represent a leading cause of morbidity and mortality for children. This study explores the intersecting effects of social deprivation and race in pediatric burn patients.

METHODS

We performed a retrospective review of all pediatric patients (<18 years old) admitted to a tertiary burn center in North Carolina from 2009 to 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans (AA) to all others. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on AA race.

RESULTS

Of 4227 children admitted, AA children were disproportionally represented, comprising 33.7% of patients versus a state population of 22.3%. AA patients had larger %TBSA with a median of 3% (IQR 1-6) compared to 2% (IQR 1-5, p < 0.001) and longer median length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8). AA patients were more likely to have autologous skin grafting compared to other races, with an adjusted RR of 1.49 (95% CI 1.22-1.83) when controlling for Area Deprivation Index (ADI) national rank, age, %TBSA, and burn type.

CONCLUSIONS

AA children were disproportionately represented and had larger burns, even when controlling for ADI. They had longer hospital stays and were more likely to have autologous skin grafting, even accounting for burn size and type. The intersection between social deprivation and race creates a unique risk for AA patients. Further investigation into this phenomenon and factors underlying surgical intervention selection are indicated to inform best treatment practices and future preventative strategies.

Retrospective outcomes analysis of tracheostomy in a paediatric burn population

INTRODUCTION

Previous analyses of tracheostomy in paediatric burns was hindered by a lack of multi-institution or nationwide analysis. This study aims to explore the effects of tracheostomy in paediatric burn patients in such an analysis. De-identified data was obtained from the TriNetX Research Network database.

METHODS

Two cohorts were identified using ICD and CPT codes: paediatric burn patients with tracheostomy (cohort 1) and paediatric burn patients without tracheostomy (cohort 2). Cohorts were matched according to age at diagnosis and pulmonary condition, specifically influenza and pneumonia, respiratory failure, acute upper respiratory infection, and pulmonary collapse. Cohorts were also matched for age at burn diagnosis and surface area burned. Several parameters including infection following a procedure, sepsis, volume depletion, respiratory disorders, laryngeal disorders, pneumonia, and other metrics were also compared.

RESULTS

A total of 152 patients were matched according to age and pulmonary condition. Cohort 1 and cohort 2 had a mean age of 4.45 ± 4.06 and 4.39 ± 3.99 years, respectively. Matched patients with tracheostomy had a higher risk for pneumonia, respiratory failure, other respiratory disorders, diseases of the vocal cord and larynx, sepsis, volume depletion, pulmonary edema, and respiratory arrest. The risk ratios for these outcomes were 2.96, 3.5, 3.13, 3.9, 2.5, 2.5, 3.3, and not applicable. Analysis of longitudinal outcomes of paediatric burn patients with tracheostomy vs. those without demonstrated the tracheostomy cohort suffered much worse morbidity and experienced higher health burden across several metrics.

CONCLUSION

The potential benefits of tracheostomy in paediatric burn patients should be weighed against these outcomes.

The epidemiology of in-hospital burn patients in a tertiary hospital in Damascus, Syria. A retrospective cohort study

BACKGROUND

Syria has been facing a dreadful crisis for the past 11 years, which has had a significant toll on the healthcare system of the country, and its ability to adequately manage acute injuries. In this research, we study the epidemiology and outcomes of burn patients admitted to the burn center of Al-Mouwasat Hospital in Damascus, Syria.

METHODS

A retrospective cohort research was conducted from January 2017 to December 2021. All accessible paper-based medical records of burn injury patients admitted to the hospital were evaluated. ABSI score was used to classify injury degrees. Chi-square test and logistic regression model were used to study the association between demographic variables and outcomes.

RESULTS

Of the 641 patients, 367 (57.3%) were males and 274 (42.7%) were females. Children represented more than half of our sample 377 (58.8%). The most common cause of burns was flame 393 (61.3%), followed by scalding 199 (31.0%). Most of the patients had a more than 10% TBSA of burns 511 (79.7%). 209 (32.6%) patients had a moderate ABSI score, followed by moderately severe in 149 (23.2%) patients. Children, patients who had high ABSI scores, and those who needed respiratory support were more likely to die than others 2.545 (1.079-6.004), 9.208 (4.061-20.879), respectively.

CONCLUSION

Death was the outcome of third of the hospitalized patients. Furthermore, Children made up more than half of the sample, and had the highest rates of leaving the hospital against medical advice. These results underline the importance of an updated nationally uniformed protocol for the management of burn patients.

Prevalence of and risk factors for nutritional deficiency and food allergy in a cohort of 21 patients with Netherton syndrome

BACKGROUND

Netherton syndrome (NS; OMIM: 256500) is a rare autosomal recessively inherited disease due to SPINK5 mutations. Hair and inflammatory skin involvement are variable along with allergies. Morbidity and mortality are high, particularly in infancy. A detailed clinical analysis of a NS patient cohort should broaden the understanding of nutritional challenges and allergic comorbidities.

METHODS

In this retrospective monocentric cohort study, medical and dietetic records of pediatric NS patients, presenting between 1999 and 2018, were reviewed. The severity of skin involvement was assessed according to the extent of the body surface area (BSA) affected by erythema.

RESULTS

We identified 21 patients with NS (median age 11.6 years). Within the first 6 months of life, requirements for fluid and kcals/protein were high for all patients (average 228 ml/kg/day) and infants had an average of 1.9 feed changes (range 0-4) due to food intolerance. Clinical evidence for IgE-mediated food allergy was present in 84.2% (16/19 children, 2 no data) with a range of 1-12 food allergies per patient. In 75%, more than one food had to be avoided. Specific IgE levels were falsely positive in 38.3% and 8/18 patients (44.4%). One-third (5/15; 6 no data) of patients, all with severe disease, had anaphylactic reactions following ingestion of fish (n = 2), sesame (n = 1), cow's milk (n = 1), and both peanut and egg (n = 1).

CONCLUSIONS

Our data emphasize feeding difficulties in children with NS and reveal an unexpectedly higher prevalence of food allergies that gives evidence to the importance of early coordinated multidisciplinary care for overcoming these challenges in NS.

Association of Pre-procedural Anxiety with Procedure-related Pain During Outpatient Pediatric Burn Care: A Pilot Study

The relationship between preprocedural anxiety and pain is not clear but has the potential to change the way pediatric patients need to be cared for prior to burn procedures. Using results from our recent randomized clinical trial among outpatient burn patients (n=90) age 6-17 years, the objective of this subsequent analysis was to assess whether preprocedural anxiety was associated with self-reported and researcher observed pain scores. Anxiety before the dressing change was assessed using an abbreviated State-Trait Anxiety Inventory for Children (range 6-21) and reported with 95% confidence intervals (CI). Self-reported pain was reported using a Visual Analog Scale (range 0-100) and observed pain was assessed using the Face, Legs, Activity, Cry, and Consolability-revised scale. Over half of patients (58.9%) reported mild anxiety (score <12) and about 5% of patients reported severe anxiety (score >16). Younger children (6-8 years) reported higher anxiety scores than older children (15-17 years), but the difference did not achieve statistical significance (mean=12.7, 95% CI: 11.5-13.9, p=0.09). Nonparametric spearman correlation indicated that anxiety score was significantly correlated with observed pain (p=0.01) and self-reported overall pain neared statistical significance (p=0.06). In the final logistic regression of reporting moderate-to-severe pain (pain score >30), the association between anxiety scores and self-reported overall moderate-to-severe pain was statistically significant (p=0.03) when adjusting for race, healing degree, and pain medication use within 6 hours prior to burn dressing care. This pilot study provides preliminary data showing that anxiety before outpatient pediatric burn dressing changes is significantly associated with self-reported overall moderate-to-severe pain.

The Role of the Immune System in Pediatric Burns: A Systematic Review

Burns are one of the most common causes of home injuries, characterized by serious damage to the skin and causing the death of affected tissues. In this review, we intended to collect information on the pathophysiological effects of burns in pediatric patients, with particular emphasis on local and systemic responses. A total of 92 articles were included in the review, and the time range of the searched articles was from 2000 to 2021. The occurrence of thermal injuries is a problem that requires special attention in pediatric patients who are still developing. Their exposure to various burns may cause disturbances in the immune response, not only in the area of tissue damage itself but also by disrupting the systemic immune response. The aspect of immunological mechanisms in burns requires further research, and in particular, it is important to focus on younger patients as the existence of subtle differences in wound healing between adults and children may significantly influence the treatment of pediatric patients.

Pediatric head and neck burns increased during early COVID-19 pandemic

Objective

The purpose of this study was to describe patterns of burns to the head and neck in children during the early COVID-19 pandemic.

Study design

This cross-sectional study reviewed pediatric patients in the Burn Care Quality Platform Registry. Patients were included if they were ≤17.9 years old and had sustained burns to the head and neck. Patients were separated into the following groups: March 13 to September 13, 2019 (before COVID-19 pandemic, BC) or March 13 to September 13, 2020 (during the initial 6 months of the COVID-19 pandemic, C19). The study team collected patient-related variables, details regarding burn injury, burn severity, and hospital course. Univariate and bivariate analyses were calculated. The chi-squared test was used for categorical variables. Statistical significance was P < .05.

Results

Fifty-five children with head and neck burn injuries were included. There was a 200% increase in burns to the head and neck region in children in April 2021 compared with previous year. Burns to head and neck in White children occurred more often during C19 (P = .03). The study revealed differences in timing of presentation (time of burn injury to emergency department admission) in different racial groups during (White children [P = .05]), and after the pandemic (African American children [P = .02]).

Conclusions

There was a transient increase in burns to the head and neck region in children during the early pandemic compared with the historic cohort.

Paediatric burn injuries in Enugu, South-East Nigeria: A 7-year multi-centre retrospective review

Burn injuries contribute significantly to childhood morbidity and mortality. This study was designed to document the pattern of presentation and outcome of pediatric burn injury in Enugu.

METHODS

All children with burn injuries over a 7-year period (June 2011 to May 2018) and were managed at three tertiary health institutions, were studied. Information including their socio-demographics, clinical features and treatment outcome were obtained and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0.

RESULTS

198 out of 201 records were available for analysis. Most (186; 93.9%) burn injuries occurred at home. Hot liquid (112; 56.7%) was the commonest cause of burn injury. A lot of substances were used topically for first aid, raw eggs (52; 31%) being the commonest. The outcome had significant association with cause of injury, depth of injury, total burn surface area (TBSA), and inhalation injury. Most were safely discharged home while a total of thirteen (6.6%) children died. LA₅₀ was 54.87%, while the maximum TBSA salvaged was 65%.

CONCLUSION

Burn injuries in children in this environment remain a serious challenge in the face of widespread lack of awareness regarding safe practices in handling hot and flammable items at home.

Pediatric Burn Care in the Developing World: Where are the Gaps in Research and What can be Done?

INTRODUCTION

Burns are the fourth most common cause of injury worldwide. The burden of burn injury is largely carried by low and middle-income countries (LMICs) with children in these regions being particularly vulnerable to burns. The purpose of this scoping review is to identify knowledge gaps in global paediatric burn care experience in an effort to help prioritise future research.

METHODS

Using the 6-stage Arksey and O'Malley framework for conducting a scoping review, paediatric burn care literature was reviewed over a ten-year period from 2010 to 2020. Studies from low-resource settings were included and categorised by geographic location, study patient population, study type, type of burn, and level of evidence.

RESULTS

Of 107 included studies, 34% and 49% originated from LMICs in South Asia and Sub-Saharan Africa, respectively. Qualitative/Observational (73%) and Epidemiological Single-Centre (20%) publications comprised the majority of included papers. The majority (95%) of all papers regardless of geographical location were lower levels of evidence (Level 3 or below).

CONCLUSION

Our study identified four primary knowledge gaps: (1) a paucity of high-quality studies to guide burn care in LMICs; (2) an under-representation of articles from certain geographical locations; (3) few therapeutic and economic articles to guide resource allocation; and (4) a lack of articles with long-term patient follow up. Efforts to address these disparities could help reduce the paediatric burn burden of disease in resource-poor settings.

Health utilities in burn injury survivors: A systematic review

BACKGROUND

An estimated 11 million burn injuries with medical attention occur every year worldwide. Although potentially deadly, burn injuries are now considered a chronic disease with multiple lifetime physical and psychological sequelae. However, it remains unclear how these events affect patients' utility scores. We aimed to conduct a systematic review to summarize the utility scores of burn injury survivors.

METHODS

We conducted on March 18^th, 2020 a systematic review of the published literature using a search strategy designed in collaboration with a research librarian. Our search strategy aimed to identify studies that provided burn injury survivors' utility scores via a standardized indirect instrument.

RESULTS

We identified 15 studies that reported burn injury survivors' utility scores. Most studies used the EQ-5D instruments to assess patients' utility scores. Results varied substantially between studies, ranging from a low of 0.06 to a high of 0.972. Our review identified two key trends. First, utility scores seem to be negatively correlated with the severity of the burn injury. Second, utility scores in adults tend to increase in function of the time since injury.

CONCLUSION

Unfortunately, due to differences in study design and settings, patient populations and instruments used to assess patients' utility scores, we were unable to combine all study results into a single value. In spite of this limit, results we identified support previous trends identified by others regarding the relationship between utility scores and the burn injury severity and/or the time since injury.

Evaluating an urban pediatric hospital's scald burn prevention program

BACKGROUND

Over 450,000 individuals are hospitalized with burns annually and roughly 35% are scald burns. Children younger than 5 years of age are at the greatest risk of scald burn injury. Caregiver burn prevention programs have been found to reduce the prevalence of injuries in young children; however, low-income and underserved populations seldomly have access to these programs. The impact of scald burn prevention programs in underserved populations remains unexplored. The objective of the current study was to evaluate the efficacy of a scald burn prevention program at a Level One Pediatric Trauma Center in a low-income, underserved community.

METHODS

Our hospital developed a one-hour scald burn prevention program for caregivers with children 5 years of age or younger. The program educated caregivers on ways to prevent scald burns and create safeguards in their home. Caregivers completed a pre-post survey to measure their ability to identify hot or cold objects, as well as respond to items about their perceptions of the program's utility, their willingness to share it with others, and the likelihood that they would use the information in the future. Data was analyzed using a paired t-test.

RESULTS

Two-hundred and sixty-nine (N = 269) caregivers participated in the program. Before the program, caregivers could identify potentially hot objects 83.17% of the time, and after the program, they were able to identify these items 92.31% of the time: t (268) = 12.46, p < .001, d = 1.07. Additionally, 95% of caregivers indicated that the program was helpful, 99% stated that they were likely to share this information with others, and 100% indicated that they would use the information from the program.

CONCLUSIONS

Education is a critical component to prevent scald burns. Results indicate that a hospital-led scald burn prevention program can positively impact a caregiver's ability to identify possible scald-burn risks. Providing education to caregivers who typically do not receive this information could lower the prevalence of scald burns not only institutionally, but in communities that are disproportionately impacted by this mechanism of injury.

An Analysis of Intracranial Hemorrhage in Wartime Pediatric Casualties

BACKGROUND

Children make up a significant cohort of patients treated at combat support hospitals. Where traumatic head injury, including intracranial hemorrhage (ICH), is well studied in military adults, such research is lacking regarding pediatric patients. We seek to describe the incidence and outcomes of ICH within this population.

METHODS

This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry for all pediatric casualties in Iraq and Afghanistan from January 2007 to January 2016. Within our dataset, we searched for casualties with an ICH.

RESULTS

Of the 3439 pediatric encounters in our dataset, we identified 495 (14%) casualties that had at least 1 type of ICH. Most were between 5 and 12 years of age, male (74%), and injured by an explosive (42%). Of the casualties with ICHs, 82 had epidural (16.6%), 237 had subdural (47.9%), 153 had subarachnoid (30.9%), 157 had parenchymal bleeds (31.7%), and 239 had ICHs not otherwise specified (48.3%). In the hospital setting, the epidural group was more frequently treated with skull decompression (41%) and craniotomy with skull elevation (28%). The subdural group was more frequently treated with a craniectomy (17%) and the parenchymal group had more frequent intracranial pressure monitoring (18%). In our dataset, 22 received ketamine prehospital (4.4%) and most were discharged alive from the hospital (79%).

CONCLUSIONS

Within our dataset, we identified 495 cases of ICH in pediatric patients. Most survived to hospital discharge despite less than half undergoing a decompression procedure.

Non-Survival Distributions in Paediatric Burn Patients; A Comparative Study of Two National Databases

A contemporary, age-specific model for the distribution of burn mortality in children has not been developed for over a decade. Using data from TriNetX, a global federated health research network, and the American Burn Association's Nation Burn Repository (NBR), we investigated non-survival distributions for paediatric burns in the United States. Paediatric burn patients ages 0-20 between 2010-2020 were identified in TriNetX from 41 Health Care Organizations using ICD-10 codes (T.20-T.30) and identified as lived/died. These were compared to the non-survival data from 90 certified burn centers in NBR database between 2016-2018. The patient population was stratified by age into subgroups of 0-4, 5-9, 10-14, 15-20 years. Overall, mortality rates for paediatric burn patients were found to be .62% in NBR and .52% in TrinetX. Boys had a higher incidence of mortality than girls in both databases (0.34% vs. 0.28% NBR, p = 0.13; 0.31% vs. 0.21% TriNetX, p = <0.001). Comparison of ethnic cohorts between 2010-2015 and 2016-2020 subgroups showed that non-survival rates of African American children increased relative to White children (TriNetX, p = <0.001), however, evidence was insufficient to conclude that African American children die more frequently than other ethnicities (NBR, p=0.054). When analyzing subgroups in TriNetX, burned children ages 5-9 had significantly increased frequency of non-survival, (p = <0.001). However, NBR data suggested that children 0-4 experience the highest frequency of mortality (p = <0.001). The non-survival distributions between these two large databases accurately reflects non-survival rates in burned children.

Negative Pressure Wound Therapy in Pediatric Burn Patients: A Systematic Review

Significance: Negative pressure wound therapy (NPWT) requires the placement of a dressing over a wound, covered with an adhesive film, and applying to these dressing a negative pressure in a controlled fashion. This therapy is a powerful complement to surgical care of wounds. Data are however poor on its use in pediatric burns. Recent Advances: This systematic review, including a total of 466 patients, shows that NPWT as the initial treatment for burned children and after skin grafting has been shown to produce promising results. In the majority of studies, skin graft take rate is close to 100%. This therapy is particularly beneficial in the pediatric population because of less frequent dressing changes and early mobilization. NPWT devices accurately quantify burns water losses and allow tailoring liquid resuscitation. Critical Issues: NPWT is not in the subject of controlled clinical trials in pediatric; most publications are case reports or retrospective reviews. The sporadic complications include bleeding, local infections, and mechanical device issues. Future Directions: NPWT has been used in 2-month up to 18-year-old children with deep second- to third-degree burn of multiple etiologies, from a few days up to several months, on small to 40% total body surface area (%), and in difficult areas. Data gathered provide empirical guidelines on NPWT use in pediatric burns using continuous mode with a pressure of -50 to -75 mmHg for children younger than 2 years, and -75 to -125 mmHg in children over 2 years of age. Prospective randomized studies are needed to provide validated rules.

A review of potential biomarkers for assessing physical and psychological trauma in paediatric burns

Biological markers that evaluate physical healing as well as psychological impact of a burn are essential for effective treatment of paediatric burns. The objective of this review is to summarize the evidence supporting the use of biomarkers in children with burns. An extensive review of the literature was performed using PubMed. A total of 59 biomarkers were identified relating to burn presence, specifically relating to processes involved in inflammation, wound healing, growth and metabolism. In addition, biomarkers involved in the stress response cascade following a burn trauma were also identified. Although many biomarkers have been identified that are potentially associated with burn-related physical and psychological trauma, an understanding of burn biology is still lacking in children. We propose that future research in the field of children’s burns should be conducted using broad screening methods for identifying potential biomarkers, examine the biological interactions of different biomarkers, utilize child-appropriate biological fluids such as urine or saliva, and include a range of different severity burns. Through further research, the biological response to burn injury may be fully realized and clinically relevant diagnostic tests and treatment therapies utilizing these biomarkers could be developed, for the improvement of healing outcomes in paediatric burn patients.

Driving improved burns care and patient outcomes through clinical registry data: A review of quality indicators in the Burns Registry of Australia and New Zealand

BACKGROUND

In 2009, the Burns Registry of Australia and New Zealand (BRANZ) published a set of clinical quality indicators (QIs) to monitor performance, improve quality of care, and inform and change policy. With several years of data collected since the initial development of the indicators for burns, the BRANZ QI Working Party reviewed the clinical QIs for relevance and meaning, and considered new QIs that had not been collected previously.

METHOD

Using published literature and expert opinion, the QI Working Party, consisting of multidisciplinary burn clinicians, reviewed the QIs for burn care to be included as routine data items in the BRANZ.

RESULTS

In July 2016, the list of clinical QIs in the BRANZ was updated to 23 QIs/data items, covering structure, process, and outcome measures. Four QIs were removed as they were not found to be useful, nine QIs/data items were revised, and eight new QIs/data items were added as they were considered to be clinically useful.

CONCLUSION

This review outlines the changes made to the QIs collected by the BRANZ four years since their development and implementation. Ongoing refinement of the BRANZ QIs will ensure that high quality data is collected to drive improvements in clinical and patient outcomes.

Does the estimation of burn extent at admission differ from the assessment at discharge?

INTRODUCTION

Estimation of total body surface area (TBSA) burnt and burn depth are among the most central parts of acute burn assessment/treatment as they determine the level and type of care needed. Traditional methods for determining burn extent on admission often lead to inaccurate estimations, especially in paediatric or overweight patients.

AIM

To compare %TBSA at admission with validated %TBSA at discharge in different patient populations to investigate if significant over- or underestimation occurs.

METHOD

This retrospective observational study is based on a patient registry of all the patients (n = 863) treated at the Uppsala University Hospital's Burn Centre between 2010 and 2018. The patients were divided into subgroups based on age, gender, body mass index (BMI) and validated burn extent. The %TBSA estimated at admission was compared to the validated %TBSA in all groups separately.

RESULTS

As has been published before, we also found that the %TBSA in paediatric patients was more often overestimated as were the smaller injuries, whereas larger injuries were often underestimated. BMI did not clearly affect the estimations and there was no clear difference between the genders in estimated %TBSA.

CONCLUSION

Inaccurate estimations of %TBSA are common, particularly for paediatric patients and small or large injuries. We recommend a careful accurate approach when calculating %TBSA in the paediatric population to avoid over- and under-resuscitation. Increased education and training are recommended to improve accurate estimation in the future.

LAY SUMMARY

The correct estimation of both extent and depth of burn is very important. This assessment guides the lever of care needed, the necessary amount of fluid resuscitation, the predicted outcome and more. It has been proven notably difficult to correct assess, especially the extent of a burn. Despite different tools as the "Rule of Nine" (body area divided into multiples of 9% body surfaces), the "Rule of Palm" (Patient's palm, fingers included, approximates 1% of body surfaces), the Lund & Browder chart (detailed, age-specific body areas) and different more technical solutions. Often inaccurate estimations are done which thus affect the treatment. This depth and extent estimation is usually performed when the patient is admitted. However, it is known that burns change appearance during the first few days of care. In our Burn Center we have also performed this estimation when the patient is discharged. At this point it is known the true extent and depth of the initial burn. In this retrospective observational study, we compared the burn extent estimated on admission with the one on discharge to investigate whether the initial assessment is accurate. This study highlights the issue of frequent inaccurate burn extent estimations, especially in subgroups as overweight patient or pediatric patients.

A state-wide analysis of pediatric scald burns by tap water, 2016-2018

INTRODUCTION

Unsafe tap water temperatures (>120 °F) are a risk factor for pediatric burns, which may disproportionally impact low-income, urban communities. We sought to estimate the incidence and demographic characteristics of tap water burns and their association with housing characteristics.

METHODS

We performed a secondary data analysis to summarize emergency department discharge records from 2016 to 2018 involving children <18 years with an ICD-10-CM code for tap water burn (X11), and town-level housing data from the American Community Survey. Unpaired student's t-test and spearman's correlation analysis were performed for comparative analyses.

RESULTS

A total of 146 tap water burn visits were identified, representing an incidence of 2 per 10,000 ED visits. The majority of cases were male, non-Hispanic White, of public insurance type, and from an urban CT town. The median age was 3 years, with 58% of cases <5 years. Towns with at least one tap water burn had a significantly higher average percentage of multi-family unit and renter housing as compared to towns with no tap water burns (p < 0.0001).

CONCLUSIONS

Our results identified a significant number of tap water burns in children. Primary prevention efforts targeting education or regulation of water temperatures may work to reduce burns in underserved areas.

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis

BACKGROUND

Trauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.

RESULTS

93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p<0.001) with no difference in mortality (1.1% vs 1.1%, p=1.00), intensive care unit (ICU) LOS (3 vs 3 days, p=0.55), or complications including decubitus ulcer (0% vs 1.1%, p=0.32), deep vein thrombosis (0% vs 0.5%, p=0.48), extremity compartment syndrome (1.1% vs 0%, p=0.16), and urinary tract infection (1.1% vs 1.1%, p=1.00).

CONCLUSION

Pediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.

Craniofacial and neck burns in the pediatric population

INTRODUCTION

Burn injuries can present with catastrophic physical and psychiatric harm with extensive, long-term sequelae. The pediatric population may especially be at-risk given this population's early neurocognitive and behavioral state of development. Innovations in treatment modalities and the development of evidence-based guidelines have helped mitigate burn morbidity and mortality in the pediatric population. Unfortunately, a surprising dearth of literature identifies risk-factors, epidemiological data, injury mechanisms, and prognostic factors within the pediatric population in the setting of craniofacial burns.

METHODS

An analysis of emergency department visits under the National Electronic Injury Surveillance System was conducted for the most recent 5-year period available (2014-2018). Available information includes demographical data, such as age and sex, mechanism of injury, visit circumstances, as well as visit disposition. Additionally, details surrounding the injury, including type of burn and anatomical location of injury, were compared.

RESULTS

After a review of results, a total of 2599 patients were included for analysis. Our study shows that infants and young children are at increased risk for grave injury 27.3% and 13% of infants and toddlers transferred or admitted, respectively, p < 0.05). 59.8% of infant burns in particular were caused by liquid or kitchen products, while 44.5% of burns in toddlers were caused by chemical products (p < 0.05 for both). Conversely, adolescents are at greater risk of burns in the setting of occupational and hobby-based activities (20.4% of adolescent burns).

CONCLUSIONS

Craniofacial burns in the pediatric population may present with complex pathology and sometimes necessitate advanced care. Presentations and prognoses are different dependent upon age and injury mechanism. These findings may serve as important framework in the establishment of guidelines for medical and legislative reform.

Volume Resuscitation in Patients With High-Voltage Electrical Injuries

Volume resuscitation of patients with high-voltage electrical injuries (>1000 V) is a more complex challenge than standard burn resuscitation. High voltages penetrate deep tissues. These deep injuries are not accounted for in resuscitation formulae dependent on percentage of cutaneous burn. Myonecrosis occurring from direct electrical injury and secondary compartment syndromes can result in rhabdomyolysis, compromising renal function and urine output. Urine output is the primary end point, with a goal of 1 mL/kg/h for adult patients with high-voltage electrical injuries. As such, secondary resuscitation end points of laboratory values, such as lactate, base deficit, hemoglobin, and creatinine, as well as hemodynamic monitoring, such as mean arterial pressure and thermodilution techniques, can become crucial in guiding optimum administration of resuscitation fluids. Mannitol and bicarbonates are available but have limited support in the literature. High-voltage electrical injury patients often develop acute kidney injury requiring dialysis and have increased risks of chronic kidney disease and mortality. Continuous venovenous hemofiltration is a well-supported adjunct to clear the myoglobin load that hemodialysis cannot from circulation.

Blast injuries in children: a mixed-methods narrative review

BACKGROUND AND SIGNIFICANCE

Blast injuries arising from high explosive weaponry is common in conflict areas. While blast injury characteristics are well recognised in the adults, there is a lack of consensus as to whether these characteristics translate to the paediatric population. Understanding blast injury patterns in this cohort is essential for providing appropriate provision of services and care for this vulnerable cohort.

METHODS

In this mixed-methods review, original papers were screened for data pertaining to paediatric injuries following blasts. Information on demographics, morbidity and mortality, and service requirements were evaluated. The papers were written and published in English from a range of international specialists in the field.

RESULTS

Children affected by blast injuries are predominantly male and their injuries arise from explosive remnants of war, particularly unexploded ordinance. Blasts show increased morbidity and mortality in younger children, while older children have injury patterns similar to adults. Head and burn injuries represent a significant cause of mortality in young children, while lower limb morbidity is reduced compared with adults. Children have a disproportionate requirement for both operative and non-operative service resources, and provisions for this burden are essential.

CONCLUSIONS

Certain characteristics of paediatric injuries arising from blasts are distinct from that of the adult cohort, while the intensive demands on services highlight the importance of understanding the diverse injury patterns in order to optimise future service provisions in caring for this child blast survivor.

A Scoping Review on the Long-Term Outcomes in Persons with Adult-Acquired Burn Injuries

Adult-acquired burn injuries are a life-altering event that can lead to debilitating functional or psychological impairments. With advancements in health care resulting in decreased mortality rates, survivors of burn injuries can expect to live longer. This warrants a shift in focus to better understand what happens to adults once they are discharged from the hospital into the community. Therefore, the purpose of this scoping review was to map the literature regarding the long-term outcomes of community-dwelling adult-acquired burn survivors. A computer-assisted literature search was conducted on literature from January 1, 2000 to August 31, 2018 utilizing four large databases (MEDLINE, EMBASE, CINHAL, and PsycINFO). Articles were included if they had a minimum of five individuals with a burn injury as a result of an accidental injury who were at least 18 years of age at the time of injury. Fifty-four articles were found suitable for inclusion in this review. The majority of studies were conducted in the United States and were longitudinal in design. Four themes were apparent from the articles: postburn complications, psychosocial outcomes, quality of life, and community participation. Data are lacking with respect to outcomes more than 5 years postburn as well as qualitative research. Furthermore, more literature is needed to understand the impact of postburn complications, coping strategies, and posttraumatic growth as well as barriers to community participation. Overall, there is an emerging body of literature that describes the long-term outcomes of adult-acquired burn survivors up to 5 years postburn.

Fluid resuscitation in paediatric burns: how do we get it right? A systematic review of the evidence

BACKGROUND

Optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and prevent complications of over-resuscitation.

OBJECTIVES

To identify studies using endpoints to guide fluid resuscitation in children with burns, review the range of reported endpoint targets and assess whether there is evidence that targeted endpoints impact on outcome.

DESIGN

Systematic review.

METHODS

Medline, Embase, Cinahl and the Cochrane Central Register of Controlled Trials databases were searched with no restrictions on study design or date. Search terms combined burns, fluid resuscitation, endpoints, goal-directed therapy and related synonyms. Studies reporting primary data regarding children with burns (<16 years) and targeting fluid resuscitation endpoints were included. Data were extracted using a proforma and the results were narratively reviewed.

RESULTS

Following screening of 777 unique references, 7 studies fulfilled the inclusion criteria. Four studies were exclusively paediatric. Six studies used urine output (UO) as the primary endpoint. Of these, one set a minimum UO threshold, while the remainder targeted a range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour. No studies compared different UO targets. Heterogeneous study protocols and outcomes precluded comparison between the UO targets. One study targeted invasive haemodynamic variables, but this did not significantly affect patient outcome.

CONCLUSIONS

Few studies have researched resuscitation endpoints for children with burns. Those that have done so have investigated heterogeneous endpoints and endpoint targets. There is a need for future randomised controlled trials to identify optimal endpoints with which to target fluid resuscitation in children with burns.

Early resuscitation and management of severe pediatric burns

Pediatric burns are a leading cause of injury and mortality in children in the United States. Prompt resuscitation and management is vital to survival in severe pediatric burns. Although management principles are similar to their adult counterparts, children have unique pathophysiologic responses to burn injury thus an understanding of the differences in fluid resuscitation requirements, airway management, burn and wound care is essential to optimize their outcomes.

Global and regional child deaths due to injuries: an assessment of the evidence

Background

Injuries result in substantial number of deaths among children globally. The burden across many settings is largely unknown. We estimated global and regional child deaths due to injuries from publicly available evidence.

Methods

We searched for community-based studies and nationally representative data reporting on child injury deaths published after year 1990 from CINAHL, EMBASE, IndMed, LILACS, Global Health, MEDLINE, SCOPUS, and Web of Science. Specific and all-cause mortality due to injuries were extracted for three age groups (0-11 months, 1-4 years, and 0-4 years). We conducted random-effects meta-analysis on extracted crude estimates, and developed a meta-regression model to determine the number of deaths due to injuries among children aged 0-4 years globally and across the World Health Organization (WHO) regions.

Results

Twenty-nine studies from 16 countries met the selection criteria. A total of 230 data-points on 15 causes of injury deaths were retrieved from all studies. Eighteen studies were rated as high quality, although heterogeneity was high (I² = 99.7%, P < 0.001) reflecting variable data sources and study designs. For children aged 0-11 months, the pooled crude injury mortality rate was 29.6 (95% confidence interval (CI) = 21.1-38.1) per 100 000 child population, with asphyxiation being the leading cause of death (neonatal) at 189.1 (95% CI = 142.7-235.4) per 100 000 followed by suffocation (post-neonatal) at 18.7 (95% CI = 11.8-25.7) per 100 000. Among children aged 1-4 years, the pooled crude injury mortality rate was 32.7 (95% CI = 27.3-38.1) per 100 000, with traffic injuries and drowning the leading causes of deaths at 10.8 (95% CI = 8.9-12.8) and 8.8 (95% CI = 7.5-10.2) per 100 000, respectively. Among children under five years, the pooled injury mortality rate was 37.7 (95% CI = 32.7-42.7) per 100 000, with traffic injuries and drowning also the leading causes of deaths at 10.3 (95% CI = 8.8-11.8) and 8.9 (95% CI = 7.8-9.9) per 100 000 respectively. When crude mortality changes over age, WHO regions, and study period were accounted for in our model, we estimated that in 2015 there were 522 167 (95% CI = 395 823-648 630) deaths among children aged 0-4 years, with South East Asia (SEARO) recording the highest number of deaths at 195 084 (95% CI = 159476-230502), closely followed by the Africa region (AFRO) with 176523 (95% CI = 115 040-237 831) deaths. Globally, traffic injuries and drowning were the leading causes of under-five injury fatalities in 2015 with 142 661 (22.0/100 000) and 123 270 (19.0/100 000) child deaths, respectively. The exception being burns in AFRO with 57 784 deaths (38.6/100 000).

Conclusions

Varying study designs, case definitions, and particularly limited country representation from Africa and South-East Asia (where we reported higher estimates), imply a need for more studies for better population representative estimates. This study may have however provided improved understanding on child injury death profiles needed to guide further research, policy reforms and relevant strategies globally.

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.

A prospective analysis of risk factors for pediatric burn mortality at a tertiary burn center in North India

BACKGROUND

None of the available mortality predicting models in pediatric burns precisely predicts outcomes in every population. Mortality rates as well as their risk factors vary with regions and among different centers within the regions. The aim of this study was to identify socio-demographic and clinical risk factors for mortality in pediatric burns in an effort to decrease the mortality in these patients.

METHODS

A prospective analytical study was conducted in patients up to the age of 18 years admitted for burn injuries in a tertiary care burn center in India from January to December 2014. Clinical and demographic data was collected through questionnaire-interview and patient follow-up during their stay in the hospital. Univariate and multivariate firth logistic regression was used to identify various risk factors for mortality in pediatric burns.

RESULTS

A total of 475 patients were admitted during the study period. Overall mortality was 31.3% (n = 149) in this study. Mean age of the patients who died was 8.68 years. Of the 149 deaths, 74 were males and 75 were females (male to female ratio = 0.98). Mean total body surface area (TBSA) involved of the patients who expired was 62%. Inhalational injury was seen in 15.5% (n = 74) of pediatric burn admissions. Mortality was significantly higher (74.3%) in patients with inhalation injury. Mortality was highest in patients with isolates of Acinetobacter + Klebsiella (58.3%), followed by Pseudomonas + Klebsiella (53.3%), Acinetobacter (31.5%), and Pseudomonas (26.3%) (p < 0.0005). Factors found to be significant on univariate firth analysis were older age, female gender, suicidal burns, higher TBSA, presence of inhalation injury, increased depth of burn, and positive microbial cultures. On multivariate analysis, higher TBSA was identified as an independent risk factor for mortality. The adjusted odds ratios for TBSA involvement was 21.706 (25.1-50%), 136.195 (50.1-75%), and 1019.436 (75.1-100%), respectively.

CONCLUSION

TBSA is the most important factor predicting mortality in pediatric burns. The higher the TBSA, the higher is the risk of mortality. Other significant risk factors for mortality are female gender, deeper burns, positive wound cultures, and inhalation injury. Risk of mortality was significantly lower in children who belonged to urban areas, nuclear family, who sustained burn injury in the last quarter of the year, and who stayed in the hospital for longer period.

Epidemiology of pediatric burns and future prevention strategies-a study of 475 patients from a high-volume burn center in North India

Background

Pediatric burns have a long-term social impact. This is more apparent in a developing country such as India, where their incidence and morbidity are high. The aim of this study was to provide recent prospective epidemiological data on pediatric burns in India and to suggest future preventive strategies.

Methods

Children up to 18 years old admitted to the Department of Burns, Plastic & Maxillofacial Surgery, VMMC & Safdarjung Hospital, New Delhi, between January and December 2014 were included in the study. Data regarding age, sex, etiology, total body surface area (TBSA), circumstances of injury, and clinical assessment were collected. The Mann-Whitney test or Kruskal-Wallis test or ANOVA was used to compare involved TBSA among various cohort groups accordingly. Univariate and multivariate linear regression analyses were used to determine the predictors of TBSA.

Results

There were a total of 475 patients involved in the study, including seven suicidal burns, all of whom were females with a mean age greater than the cohort average. Age, type of burns, mode of injury, presence or absence of inhalation injury, gender, and time of year (quarter) for admission were found to independently affect the TBSA involved. Electrical burns also formed an important number of presenting burn patients, mainly involving teenagers. Several societal issues have come forth, e.g., child marriage, child labor, and likely psychological problems among female children as suggested by a high incidence of suicidal burns.

Conclusions

This study also highlights several issues such as overcrowding, lack of awareness, dangerous cooking practices, and improper use of kerosene oil. There is an emergent need to recognize the problems, formulate strategies, spread awareness, and ban or replace hazardous substances responsible for most burn accidents.

Socio-demographic factors and the prevalence of burns in children: an overview of the literature

BACKGROUND

In most countries, socio-demographic factors influence the incidence of burns in children. The aims of this literature review were therefore to identify which of those factors are linked to an increase in the prevalence and identify ways of enhancing burn prevention programmes and preventing practices which play a role in the occurrence of burns in children.

METHOD

A comprehensive search (no time limit) of primary studies, titles and abstracts was undertaken in the following electronic databases; MEDLINE, CINAHL, ERIC, Cochrane Library, PsychInfo and Google Scholar.

RESULTS

Socio-demographic factors which were linked to an increased incidence of burns include low household income, living in deprived areas, living in rented accommodation, young mothers, single-parent families and children from ethnic minorities. The level of parental education, parental occupation, and the type and size of accommodation were also cited.

CONCLUSION

A range of socio-demographic factors result in an increase in the prevalence of burns, and the risk is even greater in children who are exposed to a number of these factors. Such information will be useful for planning prevention strategies and identifying further research questions that need to be answered.

A noninvasive computational method for fluid resuscitation monitoring in pediatric burns: a preliminary report

The fluid resuscitation needs of children with small area burns are difficult to predict. The authors hypothesized that a novel computational algorithm called the compensatory reserve index (CRI), calculated from the photoplethysmogram waveform, would correlate with percent total body surface area (%TBSA) and fluid administration in children presenting with ≤20% TBSA burns. The authors recorded photoplethysmogram waveforms from burn-injured children that were later processed by the CRI algorithm. A CRI of 1 represents supine normovolemia; a CRI of 0 represents the point at which a subject is predicted to experience hemodynamic decompensation. CRI values from the first 10 minutes of monitoring were compared to clinical data. Waveform data were available for 27 children with small to moderate sized burns (4-20 %TBSA). The average age was 6.3 ± 1.1 years, the average %TBSA was 10.4 ± 0.8%, and the average CRI was 0.36 ± 0.03. CRI inversely correlated with the %TBSA (P < .001). Twenty children were transferred with an average reported %TBSA of 16.5 ± 1.4%, which was significantly higher than the actual %TBSA (P < .001). CRI correlated better with actual %TBSA compared to reported %TBSA (P = .02). CRI correlated with the amount of fluid resuscitation given at the time of CRI measurement (P = .02) and was inversely related to total fluids given per 24 hours for children with adequate urine output (>0.5 ml/kg/hr) (P < .001). The CRI is decreased in children with small to moderate size burns, and correlates with %TBSA and fluid administration. This suggests that the CRI may be useful for fluid resuscitation guidance, warranting further study.