Annals of Burns and Fire Disasters - vol. XX - n. 2 - June 2000

THE COMPLICATIONS OF BURNS IN THE NEWBORN PERIOD

S. Golubovic Z, Parabucki D, Janjic G, Zamaklar Cl., Najdanovic Z, Rakic I.

University Children's Hospital, Belgrade, Yugoslavia

SUMMARY. Over a four-yr period we treated five children under one month of age for severe burns. All the burns were of iatrogenic origin. The injury mechanisms were: 1. bathing the child in water that was too hot; 2. use of a hot water bottle to increase the temperature in the incubator (two cases); 3. use of a hot water bottle without an incubator; 4. incorrect fitting of the thermocautery electrode to the child's crura. In all but one of the patients we used the method of tangential excision after definite demarcation of the necrotic surface. To cover the burn areas we used homograft skin from the parents and subsequently free skin transplants from the babies themselves. On the basis of our experience we consider it imperative to treat burns in neonates following the same principles as in older children. Sepsis was a major complication in one case but was adequately treated with antibiotics. Later complications were post-osteomyelitis sequelac and contractures in scars in the groin region.

Neonates and, in particular, premature infants are a high-risk population because of their immature homeopathic and immune systems. Although burn injury is very rare in this age group it is important to know how to deal with it. Frequently, even a small lesion - a minor injury compared with full-thickness skin burns - can lead to sepsis, which is often lethal at this age.' Sepsis as a complication of burns is the greatest problem, especially if it is caused by resistant hospital bacteria. The thinness of babies' skin transforms burns that in older children or adults would cause only superficial injuries into full-thickness burns.

Materials and methods

Over a four-year period, at the University Children's Hospital in Belgrade, we treated five babies aged less than one month suffering from severe burn injuries in various parts of the body. All the injuries were the product of carelessness by the medical staff or faulty medical equipment, which was not uncommon in past years in our country for well-known reasons (economic sanctions, war, etc.). All the patients were started on fluid restitution by peripheral i.v. route, local treatment of the burn area, and parenteral antibiotics.

Case reports

Patient 1
The youngest baby we treated in our hospital was a 20-day-old premature boy weighing 1700 g. He had sustained 30% TBSA burns during bathing by a nurse in another paediatric hospital. This occurred because of a faulty water tap that suddenly released hot water only (Fig. 1). The nurse realised something was wrong the moment water splashed on her hand. She herself sustained burn injuries on the first digit. The child suffered deep burns in the flank, back, perineum, and both legs. Initial rehydration was performed in the same institution and the child was thus not in a bad general condition on arrival. On admission to our hospital the burn was cleaned, the blisters were removed, and silver sulphadiazine was applied locally. Continuous parenteral rehydration and i.v. antibiotics were administered. After four days it became clear that we were dealing with deep burns, and we therefore we performed tangential excision of necrotic skin and partially covered the defects with autografts. It was very difficult to harvest autografts because of the scattered nature of the burns. The rest of the wound was covered with homografts taken from the patient's father.
Subsequently the child developed sepsis caused by methicillin-resistant Staphylococcus and arthritis of both glenointmeral joints. An intravenous combination of sulphamethoxasole and trimethroprim on the basis of the antibiogram, incision, and drainage of both shoulder joints resolved the sepsis.' All the autografts took, and the parts covered with homotransplants after reduction healed by second intention. At the age of 1 yr an operation was performed because of a scar that was pulling the hip into flexion.
The functional results are currently satisfactory, except that osteomyelitis has destroyed the proximal parts of both humoral bones, causing shortening of length and ankylosis.

Fig. 1 - Baby with deep burns in flank, back, perineum, and both legs.

Patients 2 and 3
These two patients are presented together because they sustained burns in the same incubator at the same time and in the same circumstances. Because of a power-cut, a hot water bottle was placed between the babies to provide additional warmth. The prolonged contact of the babies with the bottle caused deep burns. One baby sustained burns in the brachial and cubital regions, as well as superficial burns in the thigh and scalp (Fig. 2). The other baby sustained burns of the thigh and under-knee. After evaluation of burn depth tangential excision was performed and the defect was covered in a first operation with homografts. When the babies' general condition became stabilized the excised areas were covered with autografts in a second operation. The overall results were good, and the babies left hospital 14 days after admission.

Fig. 2 - Baby with burns in brachial and cubital region and burns of thigh and scalp.

Patient 4
This was the only burn that occurred in our hospital. It was a burn of the under-knee caused by a faulty thermocautery electrode during surgery for other reasons. Most of the burn was superficial and only a small part was deep. The burn was treated conservatively. The superficial part was quickly epithelialized, and the remainder in 10 days. There was no indication for operative treatment.

Patient 5
This child was transferred from the maternity ward of another hospital with second-degree contact burns in the face and hand caused by a hot water bottle that was used as a thermoform to keep the child warm (Fig. 3). The wounds were treated conservatively with silver sulphadiazine, resulting in good, rapid healing.

Fig. 3 - Baby with contact burn in face and hand.

Discussion

Burn injury in the neonatal period is extremely rare, especially in premature babies, and is usually the fault of medical staff. There have been few reports in the literature about such burns. They are mainly iatrogenic. The main cause is carelessness and faulty equipment. The thinness of babies' skin transforrns burns that in adults and older children would be superficial into deep burns requiring appropriate treatment. Age-related limitations of the physiological reserves of burned children mean that the adequacy of intravenous fluid resuscitation is critical. There are few reports in the literature about burns in premature babies and neonates, which explains the dilemmas posed in treatment. The points most debated regard which antibiotics and what kinds of local treatment are most appropriate for use, and whether or not to operate early. The application of 1% silver sulphadiazine markedly decreases bacterial contamination in the burned surfaces. In our experience the most important thing is to evaluate each baby singly and to have as much experience as possible in treating all burns as well as those of surgical neonates.
Our preferred method of treatment is the tangential excision of necrotic skin and the covering of the defects, preferably with autografts and very often with homografts whenever the patient's general condition and the presence of scattered burns make autografts impossible or difficult. Treatment must be rapid because these patients are in danger of sepsis, even with more banal lesions, and not only with deep and extensive burns.

RESUME. Les Auteurs, pendant une période de quatre ans, ont traité cinq enfants d'Age inférieur à un mois atteints de brûlures graves. Toutes les brillures étaient de nature iatrogéniqiue. Les causes des brdlures étaient les suivantes: 1. le bain de Fenfant effectué dans de l'eau trop chaude; 2. la bouillotte utilisée pour augumenter la température de l'incubateur (deux cas); 3. la bouillotte sans l'emploi de l'incubateur; 4. l'èlectrode du thermocautére appliqué en maniére inexacte aux membres inférieurs. Dans quatre des cinq patients les Auteurs ont utilisé la méthode de l'excision tangentielle aprés la démarcation de la surface nécrotique. Pour la couverture des zones brûlures ils ont ernployé l'homogreffe cutanée prélevée des parents, suivie par des greffes libres cutanées des enfants mêmes. Sur la base de leurs résultats les Auteurs sont convaincus qu'il est n6cessaire de traiter les brûlures des nouveaunés avec les mêmes principes utilisés dans les enfants plus Agés. L'infection a représenté une complication importante qui a été résolue en manièe efficace avec les antibiotiques. Les complications successives ont été les séquelles de l'osteomyélite et les contractures des cicatrices dans la région inguinale.

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