Have we really decreased mortality due to severe burn injury in children?

Up until recent decades, survival rates for children whom sustained severe, large percentage total body surface area (TBSA) burns were abysmal. In the 1950s, in a major burns unit in a developed country, it was documented that the mortality rate for children (≤15 years) whom sustained burns affecting ≥50% TBSA was ≥50%, increasing exponentially with increasing TBSA affected (1). In twenty-first century, developed countries, with access to technological resources, and the funding to sustain intensive public health inventions, prevention campaigns, and to provide extensive widespread community education, both the number of severe burn injuries and mortality from such injuries have significantly decreased (2-4). Mortality from burn injury in developed countries has more than halved since the 1950s (4). Recent literature suggests that children whom sustain burns to approximately 96% TBSA have a ≥50% survival rate unlike decades ago during which they most certainly would have not survived (5). A recent Australian study by Duke and colleagues, however, highlights that whilst 30 day mortality rates have significantly decreased, especially in those children who sustain large surface area burns, children who sustain burn injuries of any percentage TBSA may have a significantly greater long-term mortality rate compared to non-injured children (6).

Duke et al.’s large retrospective population based study seems to be the first of its kind, comparing over 10,000 burn injured children with a similarly matched population of over 40,000 non-injured children, with a median follow-up period of approximately 18 years (6). After adjusting for sociodemographic features and pre-existing medical histories of individuals, the authors determined that burn-injured children had a 1.6 times greater long-term mortality rate than non-injured children (6).

Injuries were the predominant cause of death in both groups, yet there was no significantly different cause of death in either group. Interestingly the median age of death also was similar in both groups (19 vs. 22 years of age in the non-injured group) (6). All mortalities occurred, prematurely, at a young age, however the authors, were restricted by their relatively short follow-up period. Traumatic deaths secondary to injury in adolescence or early adulthood could be accounted for persons whom undertake risk-taking behaviors, a factor not analyzed by Duke et al. (6,7). This could potentially be a confounder: children whom have survived such burn injuries may partake in future risky activities on the basis that they have survived a severe injury once and therefore conclude that because of this they are likely to survive again. The present study concluded that 38% of deaths in their burn injured population would have been prevented if the burn had not occurred (6). They have not accounted for the potential that these individuals may have the same personality determinates that predispose them to burns as well as other forms of traumatic injury.

The physiological and psychological effects of burn injury have been well established (8). It is unclear, however, how long these affects persist. There remains a paucity of evidence to support the notion that the physiological effects of burn injury persist for more than a few years post-injury (8). Psychological effects may potentially persist for much longer (9,10). One potential confounder of Duke et al.’s study that has not been accounted for is the potentially high prevalence of smoking and substance abuse in the psychologically vulnerable burn injured population (6). Perhaps targeting this would reduce the mortality rate in the burn injured group.

Burn injured children from this study were shown to be from low socioeconomic, disadvantaged and indigenous backgrounds (6). Whilst the authors accounted for these factors at the time of injury, they do not account for the potential significant impact burn injuries have on families. Such injuries may lead to, for example, the loss of family income, parental unemployment, social isolation and potentially parental and adolescent/young adult mental health problems and substance misuse (11). The impact is not only upon the child, but the whole family.

It is likely that the long-term mortality of children suffering from severe burn injury remains high. This study again highlights the importance of burns prevention, although perhaps there are health interventions that could be implemented for those children affected by burn injury that may reduce their potential increased long-term mortality risk. Interventions that may be beneficial may include childhood and adolescence education in regards to smoking, drug and alcohol abuse prevention, and ongoing psychosocial support of the child and their family throughout childhood and into adult life.

Acknowledgements

None.

Footnote

Conflicts of Interest: This manuscript has not previously been accepted for publication, nor published. Both authors contributed to the composition and approved the final manuscript. The authors have no conflicts of interest to declare.

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