Paediatric burns: From the voice of the child

doi:10.1016/j.burns.2013.08.031

Burns

Volume 40, Issue 4, June 2014, Pages 606-615

https://doi.org/10.1016/j.burns.2013.08.031 Get rights and content

Abstract

Introduction

Despite burns being common in children, research into the psychological experience and trauma remains limited. Improvements in the professional understanding of children's experiences will assist in improving holistic care.

Purpose

This study uses phenomenology, a qualitative methodology to explore the psychological experiences following a burn injury in children.

Methods

In-depth interviews were conducted six months after burn with 12 (six girls and six boys) children who underwent surgery for a burn. The children were aged eight to 15 years. The interview examined the overall experience of children and included probing questions exploring participants’ perceptions, thoughts and feelings. Transcripts were analysed according to the seven-step Coliazzi method. Relationships between themes were explored to identify core concepts.

Results

The findings demonstrated that trauma was central to the burn experience and comprised two phases: the burn trauma and the recovery trauma. Six themes emerged as a result of this experience: ongoing recurrent trauma; returning to normal activities; behavioural changes; scarring-the permanent reminder; family and adaptation.

Conclusion

This research has clinical implications as its findings can be used to inform clinical care at all stages of the burn journey. These research conclusions could be used to develop comprehensive information and support management plans for children. This would complement and support the surgical and medical treatment plan, providing direction for comprehensive service delivery and improved psychosocial outcomes in children.

Introduction

Burns have been described as one of the most painful injuries a person can experience and are a serious global health threat to young children [1]. In addition to the wound itself, children experience surgery, invasive, frightening medical procedures, and are often left with permanent scarring that may require future reconstructive surgery. Burns can affect an individual's wellbeing physically, psychologically, socially and functionally.

It has been clearly documented that paediatric burns affect the wellbeing of both children and their families [2]. A recent critical review of the psychological consequences of paediatric burns concluded that between 25 and 30 per cent of preschool children experience significant traumatic stress reactions during the acute phase (less than one month) after sustaining a burn [2]. Acute stress symptoms include symptoms of avoidance, hyperarousal and re-experiencing of the event [3]. These symptoms have been demonstrated in one-third of school-aged children. Ten to 20 per cent of school-aged children report symptoms of PTSD several years after the event [2]. Family and social functioning is also impaired in children with burns, but understanding is limited and there is a need for further research investigating issues of body image, coping with burn-related trauma and social life, including bullying at school [2].

Qualitative research allows the child's experience to be explored, adding an enhanced understanding of concepts not assessed by standardised measures. To date, qualitative research has focussed on children's perceptions about burns camps [4], [5]. An innovative qualitative study in South Africa explored the processes of identity negotiation in nine young adults (with a mean age of 19 years) with burns, providing insight into resilience in young adults with burns [6]. More phenomenological studies investigating children's experiences of the burn journey throughout all phases from the burn event through to discharge into the community would improve understanding and expand care provision. While it is recognised children are imbedded in a family context and this should be the focus of future research, the aim of this study was to provide an understanding of the phenomenon of the child's experience of a burn injury from their perspective. Future research investigating the parent's experience is required.

This study aimed to explore the experience of children with burns. In doing so, it aims to contribute to research by documenting the voices of child survivors, providing an improved understanding of paediatric burns from the perspective of school age children six months after burn.

Section snippets

Methods

Phenomenology was chosen as the most appropriate methodology for this study, as it allows the subjective experience of a phenomenon to be explored [7], [8]. This is useful when limited information is known about a specific phenomenon [8]. Phenomenological approaches allow the researcher to investigate the perceptions and the lived experience of a phenomenon and the associated meanings through in-depth analysis of individual's subjective experiences [8]. Phenomenology has been validated as a

Participant characteristics

Twelve children (six boys and six girls) aged eight to 15 years old who underwent surgery for a burn were interviewed in this study. All interviews were conducted within the two weeks that would mark six months after the burn occurred. Total burn surface area estimates for the injuries ranged from one per cent to 20 per cent. None of the burns sustained by the children was described as life threatening.

All children identified themselves as Australian and two children were Aboriginal. Five

Discussion

This study identified two phases of trauma central to the burn experience. Children described the first phase (the burn trauma) as the event of sustaining the burn and seeking medical assistance, whereas the second phase (the recovery trauma), involved medical procedures. This research identified that children experience ongoing trauma in addition to the initial trauma of sustaining the burn, resulting in a cumulative trauma experience. These experiences led to behavioural and emotional changes

Conclusion

The qualitative methodology of this research provides a voice for the child's perspective of the burn experience. This research has clinical implications and findings that could be used to inform clinical care at all stages of the burn journey from the perspective of the child. These research conclusions may assist the development of comprehensive information and support management plans for children. This would complement and support the surgical and medical treatment plans, providing

Conflict of interest

No authors report a conflict of interest.

Funding

This research was partly funded by a Gordon Barron-Hay Grant and an Australian Postgraduate Award.

Acknowledgements

The authors would like to thank the patients and parents on the Burns Unit at Princess Margaret Hospital for their time and honesty. We thank the staff at Ord Valley Aboriginal Health Service for their time and support and we would like to acknowledge the Gordon Barron-Hay funding body.

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This study used a descriptive qualitative approach to conduct online semi-structured interviews with caregivers (18 years and older) of children (aged four to 17 years) that had previously been admitted with an unintentional acute burn injury to a paediatric burns unit in Western Australia. Interviews explored the child’s and caregiver’s experiences throughout the burn journey from the perspective of the caregiver and were digitally recorded and transcribed verbatim. Transcripts were analysed using Braun and Clarke’s six stages of reflexive thematic analysis.
Eleven mothers participated in the interviews and identified a range of poor psychological and psychosocial outcomes that themselves and their child experienced. Three overarching themes were elaborated from the interviews: Child and caregiver mental health difficulties during and after the burn (including medical trauma, mental health outcomes and caregiver guilt); Lifestyle and physical changes following the burn (including disruptions to routine, appearance concerns and puberty); and factors supporting or inhibiting the recovery journey (including personality factors, coping strategies, family dynamics and support).
This study has presented the difficulties that children, young people, and their family face throughout a paediatric burn injury, which makes the implementation of timely and effective family centred interventions imperative. Meeting the needs and supporting these families with their mental health throughout this traumatic recovery journey, can ensure positive psychosocial outcomes and adaptive coping strategies are adopted early on.
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Citation Excerpt :
In particular, child burn victims show extreme attachment to their parents [25], avoid situations that evoke their trauma, tend to be irritable, cry and throw tantrums [3]. Due to burns, children have difficulty breathing, faint, feel fear, suffer pain, and engage in aggressive behaviors [16]. Paediatric burns have behavioral and emotional problems such as posttraumatic stress disorder, major depressive disorder, attention deficit hyperactivity disorder and separation anxiety in the first months after their burns [3].
Burns are serious injuries that can require hospitalization and have physical and emotional sequelae. Sleep disturbance can occur after trauma as evidenced by posttraumatic stress symptoms such as re-experiencing of a trauma with repetitive dreams, memories and flashbacks. This area has been minimally examined with pediatric burn survivors; therefore, the aim of this study was to investigate the effects of posttraumatic stress and general health on sleep habits of pediatric burn survivors from.
This is a correlational descriptive study. Its sample included 7–18-year-old inpatients at the burn clinic of a university hospital from January to November 2019. This study used the Posttraumatic Stress Disorder Reaction Index, the General Health Questionnaire (12) and the Children’s Sleep Habits Questionnaire for data collection.
Of the participants, 58.6% were male, 46.5% were primary school students, and 62.6% had no diseases other than their burns. 20.2% of the children had epilepsy, 14.2% had diabetes and 3% had pneumonia. Of the child burn victims, 45.5% were brought to the hospital because of contact with fire. All of them had first-degree burns, 59.6% had second-degree burns, and 80.8% had third-degree burns. After their burns, infections developed in 20.2% during trauma and in 43.4% during burn treatment. A structural equation model indicated that the child burn victims’ general health perceptions did not significantly affect their sleep habits (p > 0.05). A significant correlation was found between the children’s posttraumatic stress disorder and their sleep habits (p < 0.05). Posttraumatic stress disorder explained 7.2% of their sleep habits. A positive and significant correlation was found between the children’s general health perceptions and posttraumatic stress disorder (r = 0.74, p < 0.05).
Burns of any kind can cause posttraumatic stress, sleep disorders and impairment of health status in children.
Long-Term Outcomes in Burn Patients
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The cultural adaptation and validation of a Turkish version of the satisfaction with appearance scale (SWAP-TR)
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The aim of this study was to translate, culturally adapt and validate the Satisfaction with Appearance Scale (SWAP) into Turkish to be used in the context of pediatric burn care.
This methodological study was conducted in two stages as Language Adaptation and Psychometric study. In the first stage, the Turkish scale was obtained after expert translations. A pilot study was conducted. After back-translation, and the scale was finalized. In the second stage, the scale was administered to 145 children with burns. Body Appreciation Scale for Children (BASC) was applied to the same group for correlation analysis with the scale.
A structure explaining 65.98 % of the total variance was obtained. Cronbach's alpha values in the range of 0.995–1000 were quite reliable. A statistically significant correlation was determined between the test and retest applications for all the items (0.99–1.00) in the positive direction (p < 0.001). There is a linear negative moderate correlation between BASC scores and the scores of the SWAP-TR scale (r = −0.621 p < 0.001). The dissatisfaction scores of children with face, hand and leg burns are significantly higher than the other groups.
SWAP-TR is a reliable and valid instrument for use in a Turkish speaking children with burns. It is recommended to study the validity of this scale in other age groups with burns in Turkey.
The effect of virtual reality on pain, anxiety, and fear during burn dressing in children: A randomized controlled study
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Virtual Reality (VR) can be used during painful procedures in children. This research was conducted to determine the effect of VR on the pain, anxiety, and fear levels experienced by patients during burn dressing.
A randomized between groups study design was used to test whether VR reduced pain, fear, and anxiety during burn wound cleaning. The experimental (VR group) (n = 33) and the control group (n = 32) were determined using the simple randomization method for the children participating in the study (n = 65). The data were collected using the Wong–Baker FACES Pain Rating Scale, Children’s Fear Scale, and State- Trait Anxiety Inventory for Children. In addition, oxygen saturation and heart rate measurements were recorded before and after the procedure.
Using a between groups t-test, burn injured children in the group that received virtual reality (M = 2.6, SD = 1.9, SE= 0.21) showed significantly less pain intensity during burn wound care than the No VR control group (M = 4.2, SD =1.0, SE= 0.19, t = −5.89, p < 0.005). Similarly, the VR group reported significantly lower fear during wound care (M= 2.24, SD = 1.1, SE=0.19) than the No VR control group (M=3.72, SD = 0.6, SE=0.10, t = 6.70, p < 0.005), and on a scale from 0 to 100, patients in the VR group showed significantly less anxiety (36.46, SD = 8.1, SE=1.40) than patients in the No VR group (M= 53.16, SD = 7.4, SE=1.35, t = 8.52, p < 0.005). Heart rate during wound care was significantly lower in the VR group (M=119.60, SD = 8.1, SE=1.40) than in the No VR control group (M=129.56, SD = 10.64, SE=1.88, t = −4.25, p < 0.005). However, no significant difference in Oxygen saturation was found, (VR = 97.03, SD = 0.90, SE= 0.17, vs. No VR = 96.94, SD = 0.29, SE=0.23, t = 0.326, p > 0.05).
VR is an effective method in reducing pain, fear, and anxiety caused by burn dressing in children aged 7–12. The use of VR during burn dressing was determined to have positive results on some physical and psychological parameters.
Quality of life in paediatric burn patients with non-severe burns
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Citation Excerpt :
A negative body image has been shown to be associated with a lower quality of life [44]. A qualitative study that explored burns from the perspective of the paediatric patients showed that children were concerned about the appearance of their scars and that they avoided showing their scars, indicating that their body image is compromised [44]. A study done on adolescents with burn injuries demonstrated that children burnt after five years of age who have a clear recollection of a self-image before the burn do worse psychologically and exhibit more symptoms of depression [34].
Burns are common worldwide, and the vast majority are non-severe burns of less than 20% of the total body surface area (TBSA). In Australia, paediatric burns account for a third of all burn admissions, thus understanding the quality-of-life outcomes after a non-severe burn in children is important.
This retrospective cohort study describes a paediatric cohort from Western Australia with non-severe burns occurring between 2018 and 2020 and characterises the child’s quality-of-life outcomes which is measured using the Paediatric quality of life survey (PedsQL). The PedsQL included a parent-report and child-report assessment, each with a physical function domain and a psychosocial function domain which comprised of an emotional, a social and a school category.
Data collected from 249 patients; 50.6% were male, 45.6% were toddlers. The most common cause was scald (48.19%), the majority had burns smaller than 5% TBSA (91.97%), and most included visible areas such as head, neck or hands (77.51%). The parent-report PedsQL scores were significantly different for both physical and psychosocial domains between the different age groups (p = 0.002, p = 0.001, respectively) and for burn cause (p = 0.004, p = 0.005, respectively). For child-reported scores we found evidence of an effect of burn cause across both domains that did not reach a statistical significance (p = 0.076, p = 0.078, respectively). The psychosocial functions in both the parent-report and the self-report were significantly different for the socioeconomic status groups (p = 0.015, p = 0.032, respectively). Quality of life scores were critically low in 16.46% of paediatric burn patients at three months after burn.
Parent-reported and child-reported psychosocial function was significantly poorer in higher socioeconomic groups, for older children and for those with flame burns. About 16% of patients had scores below the critical cut off. These data provide insight into the quality-of-life outcomes of paediatric patients with non-severe burns, allowing future studies to investigate burn prevention strategies and services to help paediatric burn patients in their recovery.

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View full text

Paediatric burns: From the voice of the child

Abstract

Introduction

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Participant characteristics

Discussion

Conclusion

Conflict of interest

Funding

Acknowledgements

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

Burns

Burns

Diagnostic and statistical manual of mental disorders: DSM-IV-TR

Shedding the layers: exploring the impact of the burn camp experiance on adolescent campers’ body image

J Burn Care Rehabil

The expectations and experiences of children attending burn camps: a qualitative study

J Burn Care Res

Restorying the self: an exploration of young burn survivors’ narratives of resilience

Qual Health Res

Phenomenology and nursing research

Occupational therapy for children

Psychological research as the phenomenologist views it