Long-term posttraumatic stress symptoms vary inversely with early opiate dosing in children recovering from serious burns: effects durable at 4 years.

BACKGROUND: Children surviving serious burns are at risk for developing posttraumatic stress disorder (PTSD) as a function both of the injury and of its treatment. Short-term studies in such children have demonstrated reduced PTSD symptoms with intensive early pain control. However, the long-term impact of early pain control strategies on posttraumatic stress symptoms in children recovering from serious burn injuries has not been examined. METHODS: This was a retrospective review of a multiple time point data collection involving a cohort of 147 infants, children, and teenagers with 4 years of follow-up after serious burns conducted at 4 pediatric burn centers to examine the impact of early opiate dosing on long-term posttraumatic stress symptoms. The main outcome measure was the nine-item Short Form Child Stress Disorders Checklist, which is an established and validated assessment. The impact of total opiate dosing during the first 7 days on these scores was assessed. RESULTS: Subjects had an average age of 11 years and average injury size of 22% total body surface area burned (%TBS). The correlation between opiate units (OUs) and %TBS was 0.46 at baseline, OU increasing with increasing %TBS. OUs were strongly predictive of Child Stress Disorders Checklist scores up to 4 years, with higher OU (10 units vs. 6 and 2 units) remaining constantly different up to 4 years in predicting lower stress scores for both smaller and larger burns. CONCLUSION: Early opiate management of pain associated with acute burn wounds and burn treatment predicts the development and resolution rate of PTSD symptoms in a large multicenter sample of children hospitalized for serious burns. The effect seems to be dose related and durable at least up to 4 years in a range of burn sizes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level II.

The effects of facial burns on health outcomes in children aged 5 to 18 years.

BACKGROUND: There are many potential long-term effects of facial burns in children and young adults. We evaluated the outcomes of children and young adults with and without facial burns with respect to physical, psychological, and social domains of health-related quality of life (HRQoL). In addition, we examined the role of sex and socioeconomic status on HRQoL in these patients. METHODS: Parents of children aged from 5 to 18 years with burn injury completed the American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire when survival was ensured at their original burn center admission and at regular 6-month intervals during the first 2 years and annually up to 4 years after their acute care discharge. Generalized estimating equations with mixed models were used to evaluate the course of recovery with risk adjustments for time since burn, presence of facial burns, and clinical and other sociodemographic characteristics. RESULTS: Patients with facial burns paralleled the recovery of patients without facial burns, but their mean scores remained lower during the 4 years, with the lowest scores in the domains of appearance, emotional health, and parental concern. Teenagers had improved recovery rates when compared with younger children. Males scored lower with respect to family disruption but recovered at faster rates than females over time, and parents with higher education scored lower for parental concern during the 4 years of follow-up. CONCLUSION: Psychosocial concerns predominate in the recovery of children who sustain facial burns and are significantly greater than those observed in children in whom the face is not involved by burn injury.

Impact of hand burns on health-related quality of life in children younger than 5 years.

BACKGROUND: The purpose of this multicenter study was to evaluate the impact of hand burn injury in preschool children younger than 5 years on health-related quality of life, including both physical and psychosocial function, in the 5 years after burn injury. METHODS: This prospective case series assessed children younger than 5 years admitted to four pediatric burn centers. Each child's family completed the American Burn Association/Shriners Hospitals for Children Burn Outcome Questionnaire (BOQ), a validated and reliable assessment tool, which measures the physical and psychosocial functioning of the child with burn injury ages 0 year to 5 years, at baseline, 3, 6, 12, 18, 24, 36, and 48 months after discharge. Multivariate models controlling for sociodemographic and clinical characteristics were developed, and recovery curves were generated for the time since burn using generalized estimating equations with random effects. RESULTS: A cohort of 438 patients was followed up prospectively. Mean (SD) patient age was 2.2 (1.2) years, mean (SD) total body surface area (TBSA) was 28% (22.4%), and 19% had inhalation injury. Children with hand burns had lower scores in most of the areas tested, with the most pronounced and significant differences were in fine motor function, gross motor function, and appearance. These findings applied to both small (<20% TBSA) and large (≥20% TBSA) burns. The most profound impact of hand burns was noted in fine and gross motor function during the 4 years of follow-up. CONCLUSION: Children with hand burns have significantly worse outcomes than do children with burns in other areas.

The effect of family characteristics on the recovery of burn injuries in children.

BACKGROUND: Interactions between family members and characteristics of family life and function may affect a child's recovery from burn injury. We prospectively examined the relationship between family characteristics and physical and psychosocial recovery from burns. METHODS: The families of 399 burned children aged 5 years to 18 years admitted to one of four Shriners Hospitals for Children for management of acute burns completed the Family Environment Scale within 7 days of admission and then the American Burn Association/Shriners Hospitals for Children Burn Outcome Questionnaire (BOQ) at baseline, 3, 6, 12, 18, 24, 36, and 48 months. Generalized estimating equations with random effects for the time since burn were used to track recovery of the BOQ patient-centered domains associated with baseline family characteristics during the course of the study. RESULTS: The children had a mean age of 11 years and burn size of 32% total body surface area burned. Higher Family Environment Scale scores in cohesion, independence, organization, and active recreational orientation were associated with significantly better rates of recovery in multiple BOQ domains of health-related quality of life. Higher scores in conflict and achievement orientation predicted statistically significant impaired recovery. Higher expressiveness predicted greater difficulty with school reentry. CONCLUSION: Family characteristics affect the recovery of children after serious burns. Some of these may be amenable to focused anticipatory family interventions to help optimize outcomes. In particular, those characteristics that impair school reentry should be targeted.