Pediatric Burn Survivors Research Articles

Itch Assessment Scale for the Pediatric Burn Survivor

The objective of the study is to evaluate the validity and reliability of the Itch Man Scale developed in 2000 by Blakeney and Marvin in assessing the intensity of itch in the pediatric burn patient. Forty-five patients (31 males and 14 females; average age 9.9 ± 5.0 years; and % TBSA burned 41 ± 25%) with an established itch complaint were studied. They were asked to describe the severity of their itch by two independent raters to determine test-retest reliability. Individuals aged 6 years or older were assessed using parental informants. Concurrent validity was determined by comparing three scales to quantify the level of itch: the Itch Man Scale (a 5-point Likert scale), the 5-D Itch Scale (adapted from a scale for peripheral neuropathy), and the Visual Analog Scale for itch. Itch Man Scale ratings collected from independent raters showed a strong correlation (r = .912, P < .0001). The Itch Man Scale also correlated significantly with the Visual Analog Scale, the gold standard for measurement of pruritus (r = .798, P < .0001). The total summated score of the Duration, Degree, Direction, and Disability domains from the 5-D Itch Scale had a significant correlation with the Itch Man Scale (r = .614, P < .0001). The Degree domain is the only individual component with a significant correlation (r = .757, P < .0001). The Itch Man Scale is a reliable and valid tool to assess itching in pediatric burn patients and to quantify postburn pruritus.

Sleep Apnea: A Risk Factor for Obese Burned Children During the Rehabilitative Phase of Injury

Obesity is associated with sleep disturbances that negatively impact general health. Recent reports indicate a high prevalence of obesity in burned children during the rehabilitative phase of injury. This retrospective review examined the relationship between sleep apnea and obesity in children recovering from burn injury. Nineteen subjects (mean age 14.0 ± 0.9 years, 8.0 ± 0.9 years postburn, TBSA burn 55.6 ± 7.0%, full-thickness burn 52.7 ± 8.7%) were examined for polysomnographic and respiratory outcomes. The groups were differentiated by body mass index (BMI). The obese group was defined as having a BMI ≥90th percentile according to age and gender specifications as defined by the Centers for Disease Control and Prevention. The BMI of the nonobese group was below the 90th percentile. Using t-test or χ, sleep and respiratory recordings were compared between the obese and the nonobese groups. The mean age, percent burn, percent full-thickness burn, years following acute injury, and the percentage of patients with burns to the neck region were similar in both groups; however, by design, BMI was significantly different. Total sleep time; sleep efficiency; sleep latency and time spent in stages 1, 2, 3; and rapid eye movement were similar between groups. Nonetheless, the number of apneic episodes, respiratory disturbance index, and oxygen desaturation measures were significantly higher in the obese group. In view of the significant respiratory disturbances apparent in pediatric burn survivors, routine appraisal of respiratory symptoms during sleep is recommended. In comparison to their normal weight counterparts, obese burned children appear to be at substantially greater risk of sleep-related respiratory compromise multiple years after an acute burn injury.

Socio-economic and clinical factors predictive of paediatric quality of life post burn

Burns represent the second most common cause of non-intentional death in children under the age of five. Burns are amongst the most traumatic injuries and may impose significant psychological, educational, social and future occupational limitations to the young child. This cross-sectional study aimed to determine the socio-economic and clinical factors which predict quality of life in children with burn in a burns unit in South Africa. The Paediatric Quality of Life Inventory (PedsQL) and the Household Economic and Social Status Index (HESSI) questionnaires were administered to children and their caregivers one week and three months post discharge from the Johnson and Johnson Paediatric Burns Unit, Chris Hani Baragwanath Hospital, Soweto. The improvement in the PedsQL scores suggests that the quality of life for children three months after discharge is good despite being burnt. The severity of the burn was found to be a significant predictor of quality of life ( p = 0.00). Poor socio-economic status was clearly evident in demographic data of the subjects. The findings from this study are particularly important in identifying areas for further research that would be beneficial to developing countries. Furthermore, the results are important in the move towards more holistic care for paediatric burn survivors.

Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars

This study examined perceptions of stigmatization in a sample of 85 pediatric burn survivors and their parents. Survivors and a parent independently completed the Perceived Stigmatization Questionnaire (PSQ) rating the frequency that the child experienced three types of stigmatizing behaviors: absence of friendly behavior, confused and staring behavior, and hostile behavior. The sample was divided into a high (top 25%) and low (bottom 75%) perceived stigmatization groups. The mean ratings of parents did not significantly differ from that of children reporting low stigmatization. The mean PSQ parent ratings were significantly lower than those of children reporting high stigmatization. Additionally, the concordance on PSQ subscale scores within child–parent dyads was significantly lower in children reporting high stigmatization relative to child–parent dyads of children reporting low stigmatization. Children surviving burns may experience stigmatization that is under-perceived by their parents. Clinicians should be alert to this potential discrepancy.

After-Care of Pediatric Burn Victims: Cultural Considerations

Dear Editor, As a graduate student at John F. Kennedy University, in each of my courses I am exposed to the limitations of conventional psychological thought when working with clients of non-dominant cultures. This, in the context of my interest in the use of behavioral medicine with vulnerable pediatric populations, has led me to discover that a good part of our current medical management of various problems, most specifically pediatric burn aftercare, is essentially devoid of any information regarding diversity factors. Given the increase in pediatric burn victims and the increasing changes in ethnicity in American society, it is very likely that healthcare providers will provide acute and post-acute care to burn victims with varying cultural backgrounds and practices [1, 2]. As family support is vital to the rehabilitation of a pediatric burn survivor, creating effective rehabilitation plans requires the intentional consideration and inclusion of these, and other, factors. Family support is the leading indicator of burned children’s quality of life after discharge [3–7]. Parents are a significant source of emotional strength for their children both during hospitalization and long-term healing [4, 8]. Studies also report that a child’s physical and emotional rehabilitation are positively related to supportive family systems [9–11]. Given that family support is so critical to the long-term recovery of the child, considering culturespecific attitudes, beliefs, norms, and behaviors is imperative to creating a rehabilitation regimen to which family members can and will adhere. Misunderstandings rooted in cultural differences often result in divided doses of antibiotics, antibiotics being replaced with faith healers, alternative or complimentary medicines being used in place of or in addition to prescribed medications with no knowledge of side effects, and not scheduling or attending regular follow-up visits. In this regard, even with the best of intentions, pediatric burn victims of racial and ethnic minority backgrounds may unwittingly receive suboptimal care by healthcare practitioners. To date, research on the effects of including cultural factors in pediatric burn care, particularly aftercare, has either yet to be conducted or is not widely available in published form. Post-acute and home-based burn management (both between and within cultures) needs considerable exploration. The effects of including complimentary or alternative medicines in a rehabilitation plan for burned children have not yet been published in the literature. Research from other fields indicates that identifying and incorporating the cultural context and preferences of families can have numerous benefits, including, but not limited to, improved trust and communication between families and healthcare providers, the identification of unique strengths and potential barriers associated with treatment adherence, and increasing the perceived competency of family members to cope with and actively participate in enhancing functional outcomes [12–14]. Knowing this, culturally appropriate strategies can and ought to be developed to increase the probability of successful healing among pediatric burn victims.

Perceived stigmatization and social comfort: Validating the constructs and their measurement among pediatric burn survivors.

The current study implemented a four-step process to evaluate the measurement properties of the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) among long-term pediatric burn survivors. First, a series of confirmatory factor analyses (CFAs) compared the hypothesized four-factor model--3 perceived stigmatization factors (absence of friendly behavior, confused and staring behavior, and hostile behavior)--and one social comfort factor to three other models. Second, we tested the measurement invariance of the instruments between pediatric and adult burn survivor samples. Third, possible differences in structural parameters across groups were tested. Fourth, we tested whether the three perceived stigmatization factors and the social comfort factor loaded on one second-order factor. Participants included 369 pediatric and 347 adult burn survivors. The four-factor model was superior to the comparison models. The PSQ and SCQ demonstrated measurement invariance. Factor variance, factor covariance, and the latent means of the PSQ did not vary across groups. The adult group had a significantly lower latent mean on the SCQ than the pediatric group. The three factors of the PSQ and the one-factor SCQ loaded on one second-order factor. The results of this study lend support to both the construct validity of perceived stigmatization and social comfort and the potential value of the PSQ and SCQ for studying the social experience of people with visible differences.

Propranolol Does Not Reduce Risk for Acute Stress Disorder in Pediatric Burn Trauma

Acute stress disorder (ASD) can interfere with satisfactory recovery of children with severe burn injuries. Recent studies have found propranolol to be effective in reducing posttraumatic symptoms, but the benefits of this medication with ASD are unknown. Therefore, we hypothesized that individuals who were administered propranolol acutely would be less likely to develop ASD than those who were not. A review of electronic medical records was conducted on the children included in a previous blinded randomized-control trial, in which the participants received propranolol or no propranolol during the acute phase of recovery (first 30 days). These data were merged with electronic information regarding medication treatment for ASD. The psychologists and clinicians who had previously assessed for ASD for purposes of treating the children's distress were blinded to who received propranolol and who did not. There were 363 participants (232 boys, 131 girls) and the mean total body surface area was 56%. Of this sample, 22 participants had been previously diagnosed and treated for ASD, and 341 were in a non-ASD group. Eight percent of those children who received propranolol required treatment for ASD, whereas 5% of children who received no propranolol also required treatment for ASD. No statistically significant difference was noted. Propranolol was not found to influence the risk for subsequent ASD. This finding is in contrast to the observed benefit of propranolol reported in other studies with different at risk populations. Further exploration is warranted to assess the possible long-term benefit on posttraumatic symptoms in pediatric burn survivor patients.

Pediatric Thermal Injury: Acute Care and Reconstruction Update

The acute and reconstructive care of each pediatric burn patient presents unique challenges to the plastic surgeon and the burn care team. : The purpose of this review article is to highlight the interdependence between the acute and reconstructive needs of pediatric burn patients as it pertains to each anatomical site. Relevant principles of acute pediatric burn care and burn reconstruction are outlined, based on the authors' experience and review of the literature. The need for late reconstruction in pediatric burn survivors is significantly influenced by the acute surgical and rehabilitative treatments. With their vulnerability to airway swelling, hypothermia, pulmonary edema, and ischemia-reperfusion injury, pediatric patients with large burns require precise, life-saving treatment in the acute phase. Decision-making in pediatric burn reconstruction must take into account the patient's future growth, maturity, and often lack of suitable donor sites. Appropriately selected reconstructive techniques are essential to optimize function, appearance, and quality of life in pediatric burn survivors.

Relationships between the Quality of Life Questionnaire (QLQ) and the SF-36 among young adults burned as children

Objective To examine the relationship between two measures that can be used to examine quality life among pediatric burn survivors. Design Prospective, correlational study. Setting Acute and rehabilitation pediatric burn care facility. Participants Eighty young adult survivors of pediatric burns, who were 18–28 years of age, with burns of 30% or greater, and were at least 2 years after burn. Interventions Not applicable. Main outcome measures The SF-36 and the Quality of Life Questionnaire (QLQ) were used to assess participant's self-reported general health and long-term adjustment. Results Significant correlations ( p ≤ 0.001) were found between the total quality of life score of the QLQ and the mental component scale of the SF-36. However, no significant correlations were found between the total quality of life score of the QLQ and the SF-36 physical component scale. Conclusions Approximately 100,000 children are treated for burns annually, with a high percentage surviving, creating a challenge for health care professionals who need to prepare burn survivors with their psychosocial and physical well-being as adults. This study found that the SF-36 and QLQ are measuring somewhat different aspects of psychosocial and physical adjustment. It is recommended that both tools could be useful to the burn practitioner in assessing quality of life.

Physical and Psychologic Rehabilitation Outcomes for Young Adults Burned as Children

Baker CP, Russell WJ, Meyer W III, Blakeney P. Physical and psychologic rehabilitation outcomes for young adults burned as children. Objective To report physical and psychologic outcomes for young adult survivors of pediatric burns. Design Prospective, correlational study. Setting Acute and rehabilitation pediatric burn care facility. Participants Eighty-three young adult survivors of pediatric burns, who were 18 to 28 years of age, with total body surface area (TBSA) burns of 30% or greater, and were at least 2 years postburn. Interventions Not applicable. Main Outcome Measures Physical outcomes were assessed by muscle strength tests, grip and pinch measurements, mobility levels, and self-care (activities of daily living) skills. Psychologic outcomes included behavioral problems, personality disorder, and incidence of psychiatric illness. An individually administered Structured Clinical Interview for Diagnosis, based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, for psychiatric diagnosis, was used to assess mental health, and behavioral problems were assessed with the Young Adult Self-Report. Participants reported educational achievement, employment status, state of transition from family of origin (home) to independent living, and pair bonding. The Short-Form 36-Item Health Survey and the Quality of Life Questionnaire were used to assess each participant’s self-reported general health and quality of life. Results The majority of subjects had physical and psychologic outcomes that were within the normal range when compared with age-mates who had not experienced burns. The areas that were most likely to be impaired involved peripheral strength (wrist and grip). These deficits affected some self-care skills and correlated with TBSA. Standardized diagnostic interviews showed that greater than 50% of subjects qualified for a psychiatric diagnosis, with anxiety disorders as the most frequently occurring diagnosis. There were few significant correlations of the physical measurements or self-care skills with the burn size, psychologic problems, or social outcomes, and none appeared to be clinically important. Conclusions Most of the people in this sample were functioning physically and psychosocially within normal limits as they reached adulthood. Although they appeared to function well as measured by standardized assessments, there were indications of private suffering that suggested they may not be functioning at an optimal level. The findings suggest that rehabilitation professionals could improve outcomes by including programs to develop overall muscle strength in severely burned children and by addressing concerns related to anxiety and other symptoms of psychologic distress.

Brief Report: Quality of Life Is Impaired in Pediatric Burn Survivors with Posttraumatic Stress Disorder

This study assessed health-related quality of life (HRQOL) and posttraumatic stress disorder (PTSD) in pediatric burn survivors and examined associations between PTSD and HRQOL. Forty-three burn survivors, ages 7-16 years, were interviewed at an average of 4.4 years after their accident using the Clinician-Administered PTSD Scale for Children and Adolescents and the TNO-AZL Child Quality of Life Questionnaire. Eight children (18.6%) met DSM-IV criteria for current PTSD. While most dimensions of HRQOL were within normal limits, social functioning was impaired. Severity of PTSD was significantly associated with physical, cognitive, and emotional dimensions of HRQOL. Children with PTSD reported an impaired overall HRQOL and limited physical (e.g., more bodily complaints) and emotional functioning (e.g., more feelings of sadness). This study provides tentative evidence for a considerably high prevalence of PTSD in pediatric burn survivors and for a negative association between PTSD and HRQOL.

The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient

This retrospective review of 286 acute pediatric burn survivors treated in 2001 evaluated the effectiveness of a pharmacotherapeutic protocol for pain, anxiety, and itching. Background pain, procedural pain, exercise pain, anxiety, incidence of acute stress disorder (ASD), and itch were measured with standardized instruments. When this review was compared to similar reviews done in 1993–1994 and 1998, a steady trend toward using more potent pain medications in this patient population is evident. While the use of acetaminophen alone decreased from 50.6% of patients in 1993–1994 and 26.3% in 1998 to 7.3% in 2001, the use of opiates increased from 44.8% in 1993–1994 and 66.9% in 1998 to 81.3% of patients in 2001. Likewise, the use of benzodiazepines for anxiety has increased from 59.8% in 1998 to 77.5% of patients in 2001. During that same period the incidence of ASD decreased from 12.1% in 1993–1994 to 8.7% of patients in 2001. For effective pain and anxiety management, the average administered dose of lorazepam and morphine also increased, providing impetus to revise the pharmacotherapeutic pain protocol. Having a standard pain protocol furnishes a framework for periodic review and facilitates updating of pain and anxiety treatment practices.

Quality of Life of Young Adults Who Survived Pediatric Burns

Ninety-five young adult pediatric burn survivors, ages 18 to 28, who were an average of 14 years after massive burn, were questioned about their quality of life. The Quality of Life Questionnaire (QLQ) by Evans and Cope was used to assess their long-term adjustment in diverse environmental settings. Results revealed burn survivors as a group rated their overall quality of life lower than the normal population. They also had differences from the normal population in some subdomains of the QLQ. When analyzed by sex, only one difference was seen with females rating their involvement in sports activities lower than males. Analysis of the effect of age showed that male burn survivors had improvements with their quality of life with age and the further they were after burn. In conclusion, the ability to detect distress among burn survivors will provide targets for related treatment and subsequent assessment of efficacy of intervention.

The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient

This retrospective review of 286 acute pediatric burn survivors treated in 2001 evaluated the effectiveness of a pharmacotherapeutic protocol for pain, anxiety, and itching. Background pain, procedural pain, exercise pain, anxiety, incidence of acute stress disorder (ASD), and itch were measured with standardized instruments. When this review was compared to similar reviews done in 1993–1994 and 1998, a steady trend toward using more potent pain medications in this patient population is evident. While the use of acetaminophen alone decreased from 50.6% of patients in 1993–1994 and 26.3% in 1998 to 7.3% in 2001, the use of opiates increased from 44.8% in 1993–1994 and 66.9% in 1998 to 81.3% of patients in 2001. Likewise, the use of benzodiazepines for anxiety has increased from 59.8% in 1998 to 77.5% of patients in 2001. During that same period the incidence of ASD decreased from 12.1% in 1993–1994 to 8.7% of patients in 2001. For effective pain and anxiety management, the average administered dose of lorazepam and morphine also increased, providing impetus to revise the pharmacotherapeutic pain protocol. Having a standard pain protocol furnishes a framework for periodic review and facilitates updating of pain and anxiety treatment practices.

Measuring Perceived Stigmatization Among Pediatric Burn Survivors

The Perceived Stigmatization Questionnaire (PSQ) is a recently developed measure of perceived stigmatization (PS). Among a sample 361 adult burn survivors, the PSQ evidenced 3 factors (absence of friendly behavior, confused/staring behavior and hostile behavior), had strong reliability indices, and correlated with related constructs (Lawrence et. al., 2006). The current study tests the measurement invariance of the PSQ in a pediatric burn sample. Measurement invariance in psychological questionnaires implies that the relationship between the questions and the hypothetical construct they purport to measure (i.e., PS) is the same in different populations. Thus, scores on that measure can be compared across samples. 188 pediatric burn survivors (ages 8 to 18) completed a questionnaire packet including the PSQ. Their parents completed a demographic questionnaire. The sample characteristics were as follows: 40% female; 56% Euro-American, 22% African-American, 14% Hispanic, and 8% Other; Mean Age = 13.6 (SD = 2.5); Mean Age Burned =...

Transitions and Burn Camp - A Perfect Combination

Historically, patients sustaining extensive burns did not survive their injuries. More recently, with greater numbers of patients surviving massive burn injuries, the outcome focus has shifted from survival to meeting the functional and psychological needs of the patients. Our burn center established a burn camp in 1990 for patients 9 years to 16 years of age to assist with their psychological adjustment along with building their confidence and self-esteem. The Transitions Program evolved from the burn camp and school re-entry programs. The program was formally developed in the early 1990's by a multidisciplinary team to focus on providing patients 14 to 21 years of age with additional resources for their future. For the past 2 years, the Transitions Committee has participated in camp by hosting a Transitions Fair. Pediatric burn survivors who attend camp and are followed by the Transitions Team participate in a half-day program that includes activities and resources to assist the campers in their physical, psychosocial, vocational/educational and independent living needs. Staff members from the Transitions Team navigate the campers through four stations. These stations include an interest survey, talking one-on-one with a person in their field of interest, watching a 10 minute video on exploring future options and searching the internet for college, scholarship and employment information. After the campers visit each of the four stations, they complete an evaluation form which rates each station on a scale of 1 (least helpful) to 5 (most helpful).

Eleven Year Review of Pediatric Burn Camp: Factors Contributing to Declining Attendance

Our burn center has partnered with ACBC (Aluminum Cans for Burn Children) for 18 years providing annual pediatric camps for children admitted to the burn center. The camp allows pediatric burn survivors to interact among each other within a non-threatening environment. Children ranging from 5–18 years of age admitted to the burn center are mailed an informational packet which includes a registration form for the camp. They receive this packet annually during the ages of 5–17 even if they did not attend camp the preceding year. A decline in attendance at our camp has initiated a review of all pediatric burn patients admitted to the burn center to identify any trends. Our hypothesis is that the decline in camp attendance is due to lack of knowledge regarding the program despite mailing of informational packets and that further outreach programs are needed. Attendance data for each camp was reviewed from 1994–2004. Data was also collected from 1991 thru 2004 for the age and % TBSA (total body surface area) burn of children ages <17 admitted to our burn center.

Efficacy of a Short-Term, Intensive Social Skills Training Program for Burned Adolescents

This study examined the efficacy of an intensive, short-term social skills training program in improving the psychosocial adjustment of burned adolescents. Sixty-four adolescents who had suffered a burn injury 2 years previously or longer and who were identified as having psychosocial difficulties (elevated behavioral problems and/or diminished competence) were assigned randomly to receive the treatment intervention or to serve as controls (32 in each group). The intervention was a social skills training curriculum provided in a small group residential format. Didactic and experiential techniques were used in a schedule of activities during a 4-day period. One year after the training program, the group who had received the treatment showed significantly more improvement than did the control group. The program appears to offer advantages to a sizeable group of pediatric burn survivors and indicates the need for further study of interventions to enhance psychosocial competence in the development of pediatric burn survivors.

Early treatment of acute stress disorder in children with major burn injury

This study examines retrospectively the response rate of pediatric burn survivors with acute stress disorder to either imipramine or fluoxetine. On retrospective chart review, 128 intensive care unit patients (85 boys, 43 girls) with 52%+/- 20% total body surface area burn, length of stay of 32.8+/- 25.2 days, mean age of 9.1+/- 4.7 yrs, and age range of 13 months to 19 yrs met criteria for acute stress disorder after >or=2 days of symptoms and were treated with either imipramine or fluoxetine. If significant improvement did not occur within 7 days, the medication was either increased or switched to the other class. Initially, 104 patients were treated with imipramine and 24 with fluoxetine. A total of 84 patients responded to imipramine: seven of these patients required a higher dose. A total of 18 patients responded to initial fluoxetine treatment. Of 26 nonresponders to the initial medication, 13 imipramine failures and one fluoxetine failure refused further treatment. The other 12 responded to the second medication. Therefore, 114 of 128 treated patients (89%) responded to either fluoxetine (mean dose, 0.30+/- 0.14 mg/kg) or imipramine (mean dose, 1.30+/- 0.55 mg/kg). Response was independent of sex and age but was less for those with burns of >60% total body surface area. The side effects of each medication were not significant. Most patients continued treatment for >or=3 months; some required 6 months of treatment before successful discontinuation. Early treatment of acute stress disorder with either imipramine or fluoxetine is often able to reduce its symptoms. This is a review of a single hospital's experience in managing psychiatric distress in this very high-risk group of burned children. Additional clinical studies are needed before generalizing these findings.

Assessing the relationship between locus of control and social competence in pediatric burn survivors attending summer cAMP.

Previous research suggests that children with burn injuries often exhibit psychological and social difficulties. The areas of functioning that are affected most often include level of anxiety, social competence, and self-esteem. Those children having an internal locus of control (LOC) have been shown to react more positively to physical disorders and to have better psychological responding in nonburn populations. The purpose of this study was to determine whether there is a relationship between LOC and social competence in pediatric burn survivors. Participants were children aged 8 to 18 years who had been treated for a burn injury and attended a 1-week summer camp for pediatric burn survivors. Results indicated that the type of LOC was not a predictor of the overall level of social competence, as reported on three different measures of social competence. However, LOC significantly accounted for variability in the child's cooperation level, according to parent report. Other results are discussed, as well as implications for future research and clinical work in this area.