Development of the Preschool Life Impact Burn Recovery Evaluation (PS-LIBRE1-5) Profile.

Physical, social, and psychological outcomes have been identified as relevant to the rehabilitation process of children with burn injuries. Existing legacy measures are limited in item content and only cover a few constructs. Condition-specific outcomes are highly relevant to gauge early growth and development. Computerized adaptive tests (CATs) leveraging advanced psychometric technologies minimize respondent burden. This project developed PS-LIBRE1-5 Profile CAT (Preschool Life Impact Burn Recovery Evaluation) to measure relevant postburn outcomes in children aged one to five. Responses to the field-tested PS-LIBRE1-5 Profile (188 items) were measured on a scale of frequency or ability. Scores were coded from 0 to 4 where higher scores reflected better functioning. Factor analysis identified the items retained in the final item bank of each scale. CAT simulations were conducted to estimate the mean score of each scale. The simulated CAT score and full item bank scores were compared based upon the score range, ceiling and floor effects, and marginal reliabilities. The child mean age was 3.0 ± 1.5 years (n = 500). Average burn size and time since burn injury were 4.2% TBSA and 1.1 years, respectively. Psychometric analysis resulted in eight scales: Physical, Communication and Language, Emotional Wellbeing, Mood, Anxiety, Peer Acceptance, Play, and Peer Relations. Ceiling effects were acceptable at <13% for all scales. Marginal reliabilities of the CATs were credible. The PS-LIBRE1-5 Profile CAT contains 111 items, and is a comprehensive measure that captures physical, communication and language, psychological, and social functioning of preschool burn survivors.

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

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. Pediatric burn patients ages 0 to 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. Of the 130 acute burn patients admitted during 7/2017 to 10/2018, 10 patients met criteria for enrollment in this study. The average age was 5 years (0.8-10 years), 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 ejection fraction (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 echocardiogram examinations. No cardiac interventions were required. Use of echocardiograms is best performed on symptomatic burn patient populations.

Development of the School-Aged Life Impact Burn Recovery Evaluation (SA-LIBRE5-12) Profile: A Conceptual Framework.

Pediatric burn injuries can alter the trajectory of the survivor's entire life. Patient-centered outcome measures are helpful to assess unique physical and psychosocial needs and long-term recovery. This study aimed to develop a conceptual framework to measure pediatric burn outcomes in survivors aged 5 to 12 years as a part of the School-Aged Life Impact Burn Recovery Evaluation Computer Adaptive Test (SA-LIBRE5-12 CAT) development. This study conducted a systematic literature review guided by the WHO International Classification of Functioning-Child and Youth and domains in the American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire5-18. Interviews with eight parents and seven clinicians were conducted to identify important domains in child recovery. One clinician focus group with four clinicians was completed to identify gaps in the preliminary framework, and semiweekly expert consensus meetings were conducted with three experts to solidify the framework. Qualitative data were analyzed by grounded theory methodology. Three major thematic outcome domains emerged: 1) Physical Functioning: fine motor and upper extremity, gross motor and lower extremity, pain, skin symptoms, sleep and fatigue, and physical resilience; 2) Psychological Functioning: cognitive, behavioral, emotional, resilience, and body image; and 3) Family and Social Functioning: family relationships, and parental satisfaction, school, peer relations, and community participation. The framework will be used to develop item banks for a CAT-based assessment of school-aged children's health and developmental outcomes, which will be designed for clinical and research use to optimize interventions, personalize care, and improve long-term health outcomes for burned children.

Measuring the impact of burn injury on the parent-reported health outcomes of children 1-to-5 years: Item pool development for the Preschool1-5 Life Impact Burn Recovery Evaluation (LIBRE) Profile.

Modern, reliable, and valid outcome measures are essential to understanding the health needs of young children with burn injuries. Burn-specific and age-appropriate legacy assessment tools exist for this population but are hindered by the limitations of existing paper-based instruments. The purpose of this study was to develop item pools comprised of questions appropriate for children aged 1-5 with burn injuries. Item development was based on a framework provided by previous work to develop the Preschool Life Impact Burn Recovery Evaluation (LIBRE) Conceptual Model. The Preschool LIBRE Conceptual Model work established four sub-domains of functioning for children with burns aged 1-5. Item development involved a systematic literature review, a qualitative item review process with clinical experts, and parent cognitive interviews. Four item pools were established: (1) communication and language development; (2) physical functioning; (3) psychological functioning and (4) social functioning for preschool-aged children with burn injuries. We selected and refined candidate items, recall periods, survey instructions, and response option choices through clinical and parental feedback during the qualitative review and cognitive interview processes. Item pools are currently being field-tested as part of the process to calibrate and validate the Preschool1-5 LIBRE Computer Adaptive Test (CAT) Profile.

Efficacy of Topical Antimicrobial Agents Against Bacterial Isolates From Burn Wounds.

Topically applied antimicrobials are key to the prevention of infection and mortality in the acute burn population. The purpose of this study was to determine the in vitro effectiveness of commercially available topical antimicrobials, as well as topical preparations that were compounded in our burn care institution. One-hundred twenty microorganisms were tested against these topical antimicrobials and in vitro effectiveness was observed. Results showed that compounded preparations of 1:1:1 + Double Antibiotic (1 part bacitracin: 1 part silver sulfadiazine: 100,000 units/g nystatin + 5 mg/g neomycin sulfate + 500 units/g polymyxin B) and 3:1 + Double Antibiotic (3 part bacitracin: 1 part silver sulfadiazine + 5mg/g neomycin sulfate + 500 units/g polymyxin B) were effective against 100% of the isolates tested. Other topical agents showed moderate effectiveness, thus demonstrating the need for multiple topical agents to reach a broad spectrum of microorganisms. However, the development of topical antimicrobial resistance needs further study.

Measuring the Impact of Burn Injury on the Parent-Reported Health Outcomes of Children 1 to 5 Years: A Conceptual Framework for Development of the Preschool Life Impact Burn Recovery Evaluation Profile CAT.

Due to the rapid developmental growth in preschool-aged children, more precise measurement of the effects of burns on child health outcomes is needed. Expanding upon the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaire 0 to 5 (BOQ0-5), we developed a conceptual framework describing domains important in assessing recovery from burn injury among preschool-aged children (1-5 years). We developed a working conceptual framework based on the BOQ0-5, the National Research Council and Institute of Medicine's Model of Child Health, and the World Health Organization's International Classification of Functioning, Disability, and Health for Children and Youth. We iteratively refined our framework based on a literature review, focus groups, interviews, and expert consensus meetings. Data were qualitatively analyzed using methods informed by grounded theory. We reviewed 95 pediatric assessments, conducted two clinician focus groups and six parent interviews, and consulted with 23 clinician experts. Three child health outcome domains emerged from our analysis: symptoms, functioning, and family. The symptoms domain describes parents' perceptions of their child's pain, skin-related discomfort, and fatigue. The functioning domain describes children's physical functioning (gross and fine motor function), psychological functioning (internalizing, externalizing, and dysregulation behavior; trauma; toileting; resilience), communication and language development (receiving and producing meaning), and social functioning (connecting with family/peers, friendships, and play). The family domain describes family psychological and routine functioning outcomes.

Usefulness of a Novel System for Feedback of Patient-Reported Outcome Measures in Children Recovering From Burns.

The Burn Outcomes Questionnaire for children ages 5-18 years (BOQ5-18) is a widely used, reliable, and valid parent-reported outcome measure designed to assess children's recovery from burn injuries in 12 physical and psychosocial domains. This study evaluated the feasibility, acceptability, and usefulness of a feedback system that delivered BOQ and Pediatric Symptom Checklist (PSC-17; a widely used measure of psychosocial functioning) results to burn care clinicians prior to an outpatient appointment or a postoperative surgical encounter. The BOQ and the PSC-17 were administered to the parents of 147 children receiving outpatient or surgical care in two pediatric burn hospitals. Clinician and parent perceptions of the feedback system were evaluated using debriefing questionnaires. Over half of all patients were at-risk on at least one BOQ subscale, and risk on three or more BOQ domains was significantly associated with a higher likelihood of poor psychological scores on the PSC-17 (P < .001). Significant differences in BOQ scores were found between the two hospital sites on four BOQ subscales, three related to physical ability and one to psychosocial well-being. Parent ratings of the feedback system were positive, with 90% of parents in both settings agreeing that the BOQ tablet experience was easy and helpful. Clinician attitudes differed across the two settings with more positive clinician ratings of the system in the outpatient setting (P < .001). Clinician interviews revealed that the data was especially useful in bringing to light psychosocial aspects of functioning relevant to long-term recovery from burn injuries.

The Use of a Brief Measure to Assess Longitudinal Changes in Appearance Concerns for Youth Recovering From Burn Injuries.

Burns are among the most common injuries to children, and, although survival rates have improved, many burn survivors are left with scars and/or other visible differences, which may be associated with anxiety, depression, and/or low self-esteem. A better understanding of the prevalence and persistence of these problems in child and adolescent burn survivors might lead to an expanded paradigm of care and possibly to better outcomes. The present study provides longitudinal prevalence data for the Appearance Concerns (AC) subscale of the parent-reported Burn Outcomes Questionnaire (BOQ) for 5- to 18-year-old children and identifies patient characteristics associated with higher risk for appearance concerns. Subjects were 799 pediatric burn survivors who were assessed prospectively using the parent-reported BOQ5-18, which was administered soon after their discharge from acute care and again every 3 to 6 months for up to 4 years. Approximately 20% of all youth were reported to have appearance concerns over the first 2 years, after which the rate declined gradually, falling to around 10% after 3 years. This study showed that such concerns were prevalent and persistent years after burn injuries and suggested that larger burns, facial burns, and country of origin outside of the United States were all associated with higher scores on the AC subscale. These findings highlight the importance of assessing appearance concerns in the long-term care of young burn survivors and suggest that the BOQ5-18 AC subscale could be used to identify individuals with heightened appearance concerns and to measure their response to interventions.

Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns.

BACKGROUND: There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients. METHODS: We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010. RESULTS: Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability. CONCLUSION: The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Randomized, Paired-Site Comparison of Autologous Engineered Skin Substitutes and Split-Thickness Skin Graft for Closure of Extensive, Full-Thickness Burns.

Stable closure of full-thickness burn wounds remains a limitation to recovery from burns of greater than 50% of the total body surface area (TBSA). Hypothetically, engineered skin substitutes (ESS) consisting of autologous keratinocytes and fibroblasts attached to collagen-based scaffolds may reduce requirements for donor skin, and decrease mortality. ESS were prepared from split-thickness skin biopsies collected after enrollment of 16 pediatric burn patients into an approved study protocol. ESS and split-thickness autograft (AG) were applied to 15 subjects with full-thickness burns involving a mean of 76.9% TBSA. Data consisted of photographs, tracings of donor skin and healed wounds, comparison of mortality with the National Burn Repository, correlation of TBSA closed wounds with TBSA full-thickness burn, frequencies of regrafting, and immunoreactivity to the biopolymer scaffold. One subject expired before ESS application, and 15 subjects received 2056 ESS grafts. The ratio of closed wound to donor areas was 108.7 ± 9.7 for ESS compared with a maximum of 4.0 ± 0.0 for AG. Mortality for enrolled subjects was 6.25%, and 30.3% for a comparable population from the National Burn Repository (P < .05). Engraftment was 83.5 ± 2.0% for ESS and 96.5 ± 0.9% for AG. Percentage TBSA closed was 29.9 ± 3.3% for ESS, and 47.0 ± 2.0% for AG. These values were significantly different between the graft types. Correlation of % TBSA closed with ESS with % TBSA full-thickness burn generated an R value of 0.65 (P < .001). These results indicate that autologous ESS reduce mortality and requirements for donor skin harvesting, for grafting of full-thickness burns of greater than 50% TBSA.

Aeromedical Pediatric Burn Transportation: A Six-Year Review.

Aeromedical transportation has been shown to be a safe and efficient mode of transportation for critical care patients, including adult burn patients. Common flight concerns specific to the care of the burn patient are maintenance of intravenous lines and airway access, precision of ongoing fluid resuscitation, and effective treatment of hemodynamic instability. These concerns are particularly crucial when patients are transported by flight teams with limited burn experience. The purpose of this study was to review the safety and outcomes associated with 6 years of aeromedical pediatric burn transportation and to ascertain if differences exist when using a dedicated burn pediatric flight team versus a non-dedicated burn pediatric flight teams. Through a retrospective, IRB approved, chart review from January 2007 to January 2013, all aeromedical admissions were evaluated for demographic data, flight data, complications, and medical interventions. A total of 333 patients were transported by air, of which 282 transfers occurred during the first week of burn injury. In-flight complications occurred in <10% of patients and primarily involved airway and hemodynamic issues. There were no in-flight deaths. Patients transported by alternate teams were noted to be more hypothermic and hypotensive on admission (p < .001). Alternate teams were also noted to transfer older patients, spend less time with initial patient evaluation, and travelled shorter distances (p < .05). Aeromedical transportation of the pediatric burn patient is safe and associated with minimal complications. Communications with the transferring hospitals can facilitate transfer of the pediatric burn patient. When using alternate flight teams, particular attention should focus on resuscitation and maintenance of euthermia with large burn patients.

Outpatient burn management.

Most burn patients have injuries that may be treated on an outpatient basis. Newer silver-based dressings and improved medications for the treatment of pain and pruritus have led to further growth of outpatient care. The final barrier of distance from the burn center will decrease with the growth of telemedicine. It is incumbent for burn centers to develop outpatient guidelines to facilitate this growth of outpatient care.

A performance improvement initiative to determine the impact of increasing the time interval between changing centrally placed intravascular catheters.

Existing practice guidelines designed to minimize invasive catheter infections and insertion-related complications in general intensive care unit patients are difficult to apply to the burn population. Burn-specific guidelines for optimal frequency for catheter exchange do not exist, and great variation exists among institutions. Previously, the authors' practice was to follow a new site insertion at 48 hours by an exchange over a guidewire, which was followed 48 hours later by a second guidewire exchange (48h group). As a performance improvement initiative, the authors attempted to determine whether there would be any advantage or disadvantage to extending these intervals to 72 hours (72h). All patients with centrally placed intravascular catheters from October 2007 to August 2008 were included in the 48h group, and all patients with catheters placed from September 2008 to December 2009 comprised the 72h group. Catheter infection rates were determined using the National Healthcare Safety Network definition for central line-associated bloodstream infections (CLABSIs) and calculated as CLABSIs/1000 catheter days. The two groups were not significantly different for age, sex, burn etiology, total burn size, or percent third-degree burn. There were 3.1 CLABSIs/1000 catheter days for the 48h group and 2.8 CLABSIs/1000 catheter days for the 72h group (NS). The authors conclude that increasing the central catheter change interval from 48 to 72 hours did not result in any increase in their CLABSI rate. Implementation of this change in practice is expected to decrease supply costs by $28,000 annually in addition to reducing clinical support services needed to perform these procedures.

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.

Multimodal quantitative analysis of early pulsed-dye laser treatment of scars at a pediatric burn hospital.

BACKGROUND: The pulsed-dye laser (PDL) is a potential adjunctive therapy for treatment of hyperemic and hypertrophic scars. OBJECTIVE: To compare the effects of early PDL treatment plus compression therapy (CT) with those of CT alone in patients undergoing burn scar reconstruction with split-thickness grafts on an extremity. METHODS: Laser treatments were applied to one half of the graft seam. Standard CT was applied to both halves. Laser treatment was repeated at 6-week intervals until one half reached sufficient clinical improvements. Each half was evaluated just before treatments using quantitative measures of color, scar height, biomechanical properties and clinical features using the Vancouver Scar Scale (VSS). RESULTS: Less quantitative scar erythema and height and greater tissue elasticity were observed after two or three treatments for PDL plus compression than with compression alone. VSS scores showed greater improvement for vascularity, pliability, pigmentation, and height for PDL plus compression than for compression alone. CONCLUSION: PDL treatment in combination with CT appears to reduce scar hyperemia and height and normalize the biomechanical properties of burn-related scars.

Thrombocytopenia in the pediatric burn patient.

Thrombocytopenia is initially seen in patients with burn injury as a transient occurrence during the first week after injury. Subsequent decreases occur later in the course of treatment and are commonly due to sepsis, dilutional effects, and medication exposure. Although studies have demonstrated that thrombocytopenia in the critically ill patients is associated with a worse prognosis, there is limited literature as to the significance of thrombocytopenia in the pediatric burn patients. In this study, the authors evaluate the prognostic implications of thrombocytopenia in the pediatric burn patients. They performed a 5-year retrospective chart of patients aged 18 years or younger with burns >20% TBSA admitted to their institution. Data collected included patient demographics, burn etiology and %TBSA involvement, length of stay, pertinent laboratory values, and in-hospital morbidity and mortality. Of the 187 patients studied, thrombocytopenia occurred in 112 patients. Eighty-two percent demonstrated thrombocytopenia within the first week of injury and 18% demonstrated additional episodes of thrombocytopenia after this time. A reactive thrombocytosis occurred in 130 (70%) patients. The incidence of thrombocytopenia could not be attributed to age, gender, or burn etiology. However, patients with thrombocytopenia were more likely to have inhalation injury and extensive TBSA involvement than those without (P < .05). Sepsis was the cause of significant thrombocytopenia after the first week of hospitalization. Of the 187 patients, 14 died (7%). The incidence of thrombocytopenia in survivors and nonsurvivors was statistically significant in that nonsurvivors demonstrated a more profound drop in platelet count during the first week after injury and had a more depressed platelet recovery curve than survivors. The authors conclude that the early development of thrombocytopenia with depressed thrombocytosis in the pediatric burn patient is associated with increased mortality risk and is influenced by the extent of burn, inhalation injury, and the development of sepsis.

Respiratory arrest from Ascaris lumbricoides.

We report here the successful treatment of a 9-year-old boy who suffered a high-voltage electrical injury and a hospital course complicated by unexpected airway obstruction from Ascaris lumbricoides. Review of the literature revealed 4 previous reports of this complication. We also discuss options for prevention and treatment of this rare complication of a common infestation.

Methicillin-resistant Staphylococcus aureus furunculitis in the outpatient burn setting.

Methicillin-resistant Staphylococcus aureus (MRSA) is becoming more predominant in the community. We have seen increasing cases of furunculitis in our outpatient burn clinic, which appear to develop weeks after the initial burn injury and in patients with limited inpatient stays. We performed a 3-year retrospective review of all outpatient burn patients who developed furunculitis. Data analyzed included length of hospital stay, type of injury sustained, culture and sensitivity results, and treatment provided. A total of 28 patients were identified with MRSA furunculitis, which presented as painful, hard, indurated boils with minimal purulent drainage. Adults had less extensive burn injuries (mean of 12% TBSA adults vs 20% TBSA children) with shorter hospital stays (mean 8 days adults vs 22 days children). Fifty-seven percent of the patients had multiple furuncules, involving both burned and nonburned areas. Patients with furunculitis had a less resistant MRSA strain than those without furunculitis. Of the 22 patients who received systemic antibiotic coverage, 14 (58%) were successfully treated with 1 antibiotic regimen, whereas 8 (33%) required multiple antibiotics. In this study, furunculitis in the outpatient setting was believed to be consistent with community-acquired MRSA. Incision and drainage was not sufficient in patients with multiple furuncles, and systemic antibiotics were administered. Through increased awareness of the prevalence of community-acquired MRSA in the community, appropriate antibiotic treatment can be initiated, and the discomfort and transmission risk associated with this disease can be minimized.

Inhalation injury in children: a 10 year experience at Shriners Hospitals for Children.

Inhalation injury remains a significant source of morbidity and mortality in children with burn injury. The purpose of this study is to analyze the incidence, demographic characteristics, and outcomes for children who have sustained burn injury at one of four regional pediatric burn centers. A retrospective review of children aged 0 to 18 years admitted to one of four pediatric burn centers from 1997 to 2007 with a diagnosis of inhalation injury was performed. Factors analyzed included demographics, injury severity, treatment duration, and outcomes. A total of 850 patients with a mean age of 7.9 +/- 0.2 years and a mean total body surface area burn of 48.6 +/- 0.9% were admitted with a diagnosis of inhalation injury. Mean interval between injury and hospital admission was 4.2 +/- 0.3 days. Inhalation injury was diagnosed by bronchoscopy in 71%, via elevated carboxyhemoglobin in 4%, and by clinical signs/history alone in 25%. Hospital length of stay averaged 44.8 +/- 1.7 days, and patients required mechanical ventilation for a mean of 15.2 +/- 0.8 days. Mortality was 16.4%. Inhalation injury in children is associated with significant morbidity and mortality, and diagnosis of inhalation injury does not follow consistent guidelines. Further studies are required to standardize diagnostic criteria for inhalation injury and to optimize the treatment of children with inhalation injury.