A Study of Early Parenteral Nutritional Support and Factors Associated with Clinical Outcomes in Major Pediatric Burn Patients

Objectives: Adequate nutritional support is one of the challenging treatments of major pediatric burns. Parenteral nutrition (PN) is one of the options to achieve daily caloric goal. Latest nutritional guidelines recommend late PN initiation due to unclear benefit over risk based on the limited data. Our study provides the data of parenteral nutrition within 7 days post admission (early PN) and factors affecting clinical outcomes in major pediatric burn patients. Methods: A retrospective study was conducted regarding pediatric burn patients who had over 15% of their total body surface area (TBSA) with second- or third-degree burns. All the patients were classified as requiring early PN support or non-early PN support. Results: 124 major pediatric burns were reviewed. Eighty-six patients (65.2%) were male, and the median age was three years (0.3-15 years). Early PN showed no association with length of hospital stay (LOS) (p=0.480) or a 30-day mortality (p=0.529). The children’s age, wound infections, and abdominal distension were the independent associated factors of LOS (p=0.025, 0.001, and 0.003 respectively). Pneumonia and urinary tract infection were independent factors associated with 30-day mortality (p=0.025). Conclusions: Early PN in acute pediatric burns was not associated with LOS or 30-day mortality. It can be considered as options of nutritional support in acute, major pediatric burns. Effective management of wound infections and abdominal distension may reduce LOS.

Pediatric burns unique characteristics among Ultra-Orthodox Jewish minority - retrospective study

Background and Objectives Burn injuries are a significant cause of morbidity among children. Ultra-Orthodox Jewish children are at higher risk for burn injuries. The goal of this study was to examine the clinical characteristics of moderate to severe burns in this population in comparison to the general population in Israel. Methods This retrospective cohort study included all pediatric patients 0-18 years of age admitted with burn injuries from January 1, 2015 through December 31, 2018. Data was collected regarding demography, etiology and clinical characteristics. Results Of 778 burns injuries presented to our tertiary center, 385 (49.5%) were hospitalized. Of those 212 (55%) were non-Ultra-Orthodox Jews, 135 (35%) were Ultra-Orthodox Jews, and 38 (10%) were non-Jewish patients. The Total Body Surface Area percentage (TBSA%) of scald-type burns was larger in Ultra-Orthodox compared to non-Ultra-Orthodox children (median TBSA% of 7% Vs 5% respectively(p<0.05)). Among the Ultra-Orthodox group, the median TBSA percentage during weekdays was 6%, and for weekends the TBSA% was 7.5% (p<0.05). Females demonstrated the greatest diversity between subgroups. On weekends, Ultra-Orthodox female’s median TBSA% was 10%, and non-Ultra-Orthodox female’s TBSA% was 4.5% (p<0.05). Conclusions Ultra-Orthodox children and especially girls had a significantly higher median TBSA% than non-Ultra-Orthodox children for burns occurring during weekends. This may be the result of the unique cultural norms of the Ultra-Orthodox Jewish community, in particular, their lifestyle and observation of the Sabbath. These findings provide focus for better intervention and prevention of pediatric burns among this unique population.

Approaches of Emergency Department Physicians to Pediatric Burns: A Survey Assessment

Burned children generally arrive at emergency departments before referring to specialized burn centers. Their initial treatments are performed by non-burn doctors who work in emergency departments. The aim of this study was to evaluate emergency department doctors’ knowledge regarding the initial interventions and transfer of pediatric burn patients. There were 196 participants who completed the survey: 59 were emergency medicine specialists, 46 were general practitioners, and 91 were emergency medicine residents. Sixty-five stated that they always calculate the burn surface areas, and 144 stated that the Parkland formula should be used to calculate the fluid requirements for the first 24 hours. Of all participants, only 21 marked the correct choice as the Lund-Browder scheme to calculate the total burned surface area in children. Only 52 participants marked the correct choice as the Lactated Ringer’s of the fluid given in the first 24 hours. Only 108 correctly recognized inhalation injury. To the question “What is the first intervention that doctors should do at the emergency room to burned children?”, 127 participants stated correctly as the assessment of airway maintenance. Among the participants, 124 stated that they use lidocaine pomades when covering burned children’s wounds. Incorrect interventions with burned children increase morbidity and mortality. This survey shows that non-burn doctors working in emergency departments have insufficient knowledge about pediatric burns and require further training. Therefore, they should be trained continuously and regularly on the approach to both adult and childhood burns.

Pediatric burns with cyanoacrylate glue - an inconspicuous danger

Burns are a common cause of pediatric injury and represent significant morbidity and mortality in this age group. In children, most burns are thermal, resulting from exposure to a hot surface, liquid, or fire. Cyanoacrylate is a liquid compound commonly found in households, mainly in “superglue” and nail glue. This compound solidifies through an exothermic reaction that is magnified when in contact with certain fibers that act as catalysts, such as cotton. In these circumstances, intense heat is produced in the contact area, potentially causing severe thermal burns. Despite its widespread availability, there is a paucity of safety information about cyanoacrylate and its role as a cause for burns. In the literature, only 18 cases of cyanoacrylate burns are reported in children. We present 2 cases of pediatric burns with cyanoacrylate and a review of the literature.

Is the Use of Routine Echocardiogram Warranted in Large Pediatric Burns?

Introduction Cardiac dysfunction can develop in large pediatric burns during the acute and recovery phase. When occurring in this population, the cardiac abnormality appears as left ventricular dysfunction or dilated cardiomyopathy. Recent studies have demonstrated perioperative and long-term cardiac dysfunction resulting in longer hospital stays for patients over 40% total body surface area. The objective of this study was to assess if early use of echocardiograms in large burns would allow for early recognition of patients at risk for cardiac dysfunction. Material and Methods Pediatric burn patients ages 0-18 years who sustained a burn injury of 30% TBSA or more or developed cardiac dysfunction during hospital course were evaluated. Echocardiograms were obtained upon admission with monthly repeats until three normal studies were attained or the patient was discharged and when symptomatic. Results Of the 130 acute burn patients admitted during 7/2017-10/2018, 10 patients met criteria for enrollment in this study. The average age was 5 years (0.8 to 10 yrs), 70% were males and 90% sustained flame injuries.Total TBSA average was 45% (24-70%) with average full thickness burns of 33% (0-67%). Twenty echocardiogram studies were obtained. One patient with 25% TBSA burn, demonstrated severe left ventricular dysfunction with an EF of 25% from post arrest myocardial stunning. Repeat echocardiogram studies demonstrated full recovery with normal EF. The remaining patients, despite large TBSA injuries, did not exhibit any abnormalities on ECHO examinations. No cardiac interventions were required. Conclusions Use of echocardiograms is best performed on symptomatic burn patient populations.

520 Weight-based vs. BSA-based Fluid Resuscitation Predictions in Pediatric Burn Patients

Introduction Current practice for major pediatric burns includes fluid resuscitation using formulas that estimate fluid requirements based on weight and/or body surface area (BSA) along with percent total burn surface area (TBSA). Adult studies have shown that these formulas can cause fluid overload in obese patients and increase risk of complications. These findings have not been validated in pediatric patients. This study aims to evaluate whether a weight-based resuscitation formula increases the risk of complications in obese children following burn injuries and compares fluid estimates to those that incorporate BSA. Methods A retrospective review was conducted on 110 children (≤ 18 years old) admitted to an ABA-verified urban pediatric burn center from October 2008 to May 2020. Patients had ≥15% TBSA, were resuscitated with the weight-based Parkland formula, and had fluids titrated to urine output every two hours (1 ml/kg/hr if ≤ 30kg; 0.5 ml/kg/hr if > 30kg). Demographics, burn type, and TBSA were collected on admission. BSA-based Galveston and BSA-incorporated Cincinnati formula resuscitation predictions were also calculated. Output and input volumes were collected at 8h and 24h post-injury. Complications were collected throughout the hospital stay. Patients were classified into CDC-defined weight groups based on percentile ranges. Statistical analysis was conducted using SPSS Statistics version 10.0. Results This study included 11 underweight, 60 normal weight, 18 overweight, and 21 obese children. Our patients had a mean age-based weight CDC percentile of 62.2%, and mean TBSA of 25.4%. Predicted resuscitation volumes increased as CDC percentile increased for all three formulas (p=0.033, 0.092, 0.038), however there were no significant differences between overweight and obese children. Total fluid administered was higher as CDC percentile increased (p=0.023). However, overweight children received more total fluid than obese children. The difference between total fluids given and Galveston predicted resuscitation volumes were significant across all groups (p=0.042); however, the difference using the Parkland and Cincinnati formulas were not statistically significant. There were more children in the normal weight group who developed complications compared to other groups, but these findings were not significant. Conclusions The Parkland formula tended to underpredict fluid needs in the underweight, normal weight, and overweight children, and it overpredicted fluid needs for the obese. Further research is needed to determine the value of weight-based vs BSA-based or incorporated formulas in terms of their risk of complications.