Burns in Children Younger Than Two Years of Age: An Experience With 200 Consecutive Admissions

Children <2 years of age are at increased risk of sustaining burn injury and are considered more difficult to manage than older children. We performed this data collection to facilitate better understanding of the clinical characteristics of this unique subpopulation of injured children.We collected data on 200 consecutive children <24 months of age who required admission to a regional pediatric facility between September 1, 1991 and August 22, 1993 for management of acute burns. The Shriners Burns Institute is a 30-bed regional facility that is verified as a pediatric burn center by the American College of Surgeons and American Burn Association Burn Center verification process. It provides comprehensive acute and long-term free care to children with burn injuries. We have a very busy outpatient clinic and commonly manage small burns in the outpatient setting; however, children managed as outpatients were not included in this review. Criteria for outpatient management include: 1) a burn that is <15% of the body surface so that fluid resuscitation is not required, 2) the ability to take fluids by mouth (excludes children with significant perioral burns), 3) no suggestion of possible airway involvement (no suggestion of hot liquid aspiration), 4) reliable family with transportation resources that will allow for clinic visits, and 5) no question of abuse.Children were managed uniformly, emphasizing prompt wound excision and closure.1 Children with small (<10% of the body surface) scald burns were treated with topical therapy with dressing changes generally once daily. When, after 3 to 7 days of such therapy, a full-thickness component was clearly evident on physical examination, they underwent surgery for excision and autografting of this component. Clean superficial wounds were generally covered with porcine xenograft (Mediskin, Brennen Medical, St Paul, MN) until healed. Children with obvious full-thickness injury, particularly those with wounds >15% of the body surface, were promptly operated, generally within 48 hours of injury. When donor sites were insufficient to provide immediate definitive closure of excised wounds, human allograft was placed. This was removed and replaced with autograft from donor sites harvested previously as soon as the wounds healed, generally within 7 to 10 days of initial harvest. Anabolic agents were not used. Cultured keratinocytes were used in two children with burns >90% of the body surface to provide partial wound closure.2 Children who required mechanical ventilatory support for airway protection or respiratory failure had their inflating pressures and oxygen concentrations capped at 40 cm H2O and .60% Fio2, respectively, except in exceptional circumstances, as described previously.3 Central venous catheters were replaced by guide wire or rotated to a new site every 7 days.4Nutritional support was emphasized, and nasogastric tube feedings were the mainstay of therapy, parenteral support being reserved for those children intolerant of nasogastric feeds or who required frequent trips to the operating room. Results are presented as mean ± standard deviation.These 200 children had an average age of 13.4 ± 5.5 months (range, 1 to 24 months), average weight of 10.5 ± 2.2 kg (range, 4.2 to 16.5 kg), and average burn size of 10.1 ± 13.8% of the body surface (range, 0.1% to 95%). There were 122 boys and 78 girls. There were 127 children with burns involving <10% of the body surface, 44 with burns involving 10% to 19%, 24 with burns involving 20% to 49%, and 5 with injuries involving >50%. There were 122 Caucasian, 22 Hispanic, 32 Black, and 10 Asian children; the data were not recorded for the remainder. Significant medical history included thalassemia (1 child), inguinal hernia (2 children), pyloric stenosis (2 children), long bone fracture (2 children), cardiac defect (2 children), meningitis (1 child), muscular dystrophy (1 child), Erb's palsy (1 child), intussusception (1 child), prematurity (3 children), retinopathy (1 child), intraventricular hemorrhage (1 child), febrile seizures (2 children), previous burns (1 child), asthma (10 children), and otitis media (17 children).Mechanisms of injury included flame (11 patients, 5.5%); tub scald (25 patients, 12.5%); spilled scald (109 patients, 54.5%); contact, particularly with clothing or curling irons (47 patients, 23.5%); chemical (1 patient, 0.5%), high voltage (1 patient, 0.5%); and other (5 patients, 2.5%). Central venous catheters were used in 27 (13.5%) of the children, arterial lines in 9 (4.5%), bladder catheters in 37 (18.5%), endotracheal tubes in 13 (6.5%), and tracheostomy in 1 (0.5%). Total parenteral nutrition was used in 12 children (6%), and tube feedings in 28 (14%). Thirteen children (6.5%) required mechanical ventilatory support. Seven had inhalation injury, and 3 were suspected to have aspirated hot liquid. There were 192 operations required: 10 children (5%) had allograft used, and 2 children (1%) with burns of 90% and 95% had cultured autologous epithelium used. Porcine xenograft was used on partial thickness burns in 67 children (33.5%). Serious nosocomial infectious complications included pneumonia in 6 children (3%), urinary tract infection in 4 (2%), Gram-positive bacteremia in 7 (3.5%), Gram-negative bacteremia in 2 (1%), and candidemia in 2 (1%).Children were hospitalized an average of 15.2 ± 19.6 days (range, 1 to 174), which represented 4.0 ± 8.7 (median, 1.7 days; range, 0.17 to 100) days per percent body surface burn. However, this figure decreased sharply as burn size increased, with the 73 children with burns ≥10% (average 21 ± 16% of the body surface) hospitalized for 1.4 ± 2.0 days per percent body surface burn and those 29 children with injuries involving ≥20% of the body surface (average 34 ± 20% of the body surface) hospitalized for 1.1 ± 0.8 days per percent body surface burn. Our facility also provides burn rehabilitation and these hospital days included all rehabilitation stays, with only one child being transferred to a rehabilitation hospital closer to his home in another state.Injuries were filed with state social service agencies in 37 cases (18.5%), and the outcome of these filings was home with services in 17 cases (45.9%), foster care in 6 cases (16.2%), home with investigation of alternate care giver in 5 cases (13.5%), home with case open in 4 cases (10.8%), and no action in 4 cases (10.8%). A filed injury occurred in a child already in state custody in 1 case (2.7%). No child was readmitted with a second burn injury, and we are aware of no admissions for other injuries. All children were discharged home except for those sent to foster care and one child who was transferred to a rehabilitation facility. There were no deaths.Children <2 years of age are at increased risk of sustaining burn injury,5 and in many respects are more difficult to manage than older children. Several authors have emphasized the increased morbidity and mortality associated with burns in this age group. Morrow et al6 reported that increasing burn size and decreasing age were statistically significant predictors of mortality by logistic regression analysis. Erickson et al7 reported that children <48 months of age had more than twice the mortality rate of older children and adults with equivalent injuries. Our data seem to be at variance with this experience. However, this paper is not an effort to prove that any one approach to burn care is superior. Specifically, although we do practice early excision and closure of full-thickness burns, these descriptive data cannot be used to show that this policy will decrease mortality or shorten hospital stay.Conclusions that we have drawn from this data collection include the following: 1) significant comorbidities are common in burned young children; 2) length of hospital stay is ∼1 day per percent burn in those children with large injuries (including rehabilitation days); 3) the most common mechanisms of injury involve scalding by spill or immersion in hot liquid and by contact with clothing or curling irons; it is here that prevention efforts should focus; 4) almost 20% of cases are referred to state social services for investigation in this age group, and almost 20% of these children were discharged to foster care; 5) invasive support devices can be used in children with serious burns with an acceptably low incidence of infectious complications; and 6) children <24 months of age can be expected to survive serious burns when managed in an organized manner emphasizing prompt wound closure.This work was supported by the Shriners Hospitals for Children.