Elsevier

Burns

Volume 40, Issue 8, December 2014, Pages 1530-1537
Burns

Evidence based management for paediatric burn: New approaches and improved scar outcomes

https://doi.org/10.1016/j.burns.2014.01.020Get rights and content

Abstract

Little evidence has been produced on the best practice for managing paediatric burns. We set out to develop a formal approach based on the finding that hypertrophic scarring is related to healing-time, with durations under 21 days associated with improved scar outcome. Incorporating new advances in burn care, we compared outcomes under the new approach to a cohort treated previously.

Our study was a retrospective cross-sectional case note study, with demographic, treatment and outcome information collected. The management and outcome of each case was assessed and compared against another paediatric burns cohort from 2006.

181 burns presenting across a six month period were analysed (2010 cohort) and compared to 337 children from a previous cohort from 2006. Comparison of patients between cohorts showed an overall shift towards shorter healing-times in the 2010 cohort. A lower overall rate of hypertrophic scarring was seen in the 2010 cohort, and for corresponding healing-times after injury, hypertrophic scarring rates were halved in comparison to the 2006 cohort.

We demonstrate that the use of a structured approach for paediatric burns has improved outcomes with regards to healing-time and hypertrophic scarring rate. This approach allows maximisation of healing potential and implements aggressive prophylactic measures.

Introduction

In 2006 we published a paper on the evidence for the link between healing time and the development of hypertrophic scars in paediatric burns [1]. In 2008 the senior author was appointed to the burns centre at Queen Victoria Hospital (QVH), East Grinstead, UK, and the management approach for paediatric burn now follows on from the principles demonstrated in the 2006 paper.

The new paediatric burns treatment approach at QVH is intended to effectively manage a burn in order to optimise healing time and therefore the outcome of the injury (see Fig. 1). Our data and that of other authors demonstrate that healing time correlates with physical outcome [1], [2], in particular the development of hypertrophic scarring for which healing beyond 21 days is thought to be a risk factor. Intervening to reduce healing time to within the documented 21 day window is the basis of the new approach, without over-treating burns that would otherwise heal well within this time. The use of diagnostic aids such as laser Doppler imaging (LDI) and formal review after 48 h to assess healing potential is key to ensuring appropriate treatment. Early assessment of healing potential therefore allows the selection of biological dressings or early skin grafting to facilitate early healing. We have also previously published data on the appropriate use of outpatient follow up clinics to ensure that patients only attend clinic when this has a definite benefit [3]. For the majority of patients follow up is indicated by scar development, therefore our current follow-up plan reflects this approach. However patients with complex problems, especially child protection issues, are usually seen monthly.

We set out to establish if the incorporation of these current methods in light of previously collected evidence could result in improved healing time following injury. A study was carried out to review six months of paediatric burn patients and compare their management and outcomes with the previously published cohort studied before the establishment of the new approach.

Our previous study demonstrated that a healing time of 21 days or less leads to the best long-term outcomes for patients in regard to scarring. Healing time is therefore our primary performance indicator with regard to burn outcome. We also assessed whether new technologies such as LDI and biological dressings are being used appropriately in patients and whether available follow-up services have been used to maximum benefit.

Section snippets

Study design

The study comprised of a six month retrospective case note review of all paediatric burns managed at QVH between May and October 2009 to allow an adequate follow-up period. Inclusion in the sample required treatment at QVH for a burn and being 16 years of age or younger. We excluded patients with significant omissions in their hospital notes for documentation of either total body surface area of burn (TBSA), wound location, wound depth, or healing time. Comparison was made with a cohort

Epidemiology of patients and presenting burns

181 patients were treated at QVH between the inclusion dates for the sample population. Eleven patients were excluded due to significant omissions from documentation. We compared this cohort (referred to as the 2010 cohort) to the patients reported in our previous publication (referred to as the 2006 cohort), comprising 337 patients for whom follow up was possible out of a cohort of 509 presenting injuries [1]. All patients in the 2010 cohort were followed up successfully. Follow-up time in

Discussion

Our study aimed to investigate whether the adoption of a new approach to paediatric burn has lead to an improvement in outcome at our centre. The main rationale for our approach being to balance maximising healing potential against over-treating children with invasive surgical procedures, we chose hypertrophic scarring and healing time as measures by which to test our current practices.

We compare a recent cohort of paediatric burn patients to a historical set treated by the senior author for

Conclusion

Our study demonstrates that the use of an evidence-based approach to the management of paediatric burns results in superior outcomes regarding healing time and hypertrophic scarring. This involves maximising healing potential through identifying the most appropriate treatment and providing aggressive prophylactic measures against hypertrophic scarring where healing time indicates this may be a risk. In addition, we have produced a framework in which new technologies such as LDI and biological

Conflict of interest

None.

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