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Melanie Cole:  Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we discuss burn care for pediatric patients and the principles of pediatric burn management. Joining me in this panel are Dr. Shawn Larson, he's the medical director of the UF Health Shands Children's Hospital Pediatric Trauma and Burn Program, and Lauren Indelicato, she's a nurse practitioner at the University of Florida in the Division of Pediatric Surgery. Thank you both so much for joining us today. And Dr. Larson, I'd like to start with you. Tell us why pediatric trauma and burn injury is such a significant public health issue. What are you seeing in the trends and why are burns so common?

Dr. Shawn Larson: Well, thank you, Melanie, for having us. That's a very good question. So pediatric trauma is the leading cause of death of children from the age of one all the way up to the young age of 44 years of age. A lot of those mechanisms of injury, including burn injury, are preventable. When we're talking about pediatric burns and being preventable, it really, a lot of times, comes down to adult supervision of the children, making sure that they don't have access to chemicals and common household and garage things like gasoline and diesel fuel. We live in North Central Florida, which is a kind of a combination of suburban as well as rural areas, and we have a lot of our families that burn trash, burn leaves, burn brush, and will sometimes use things like gasoline or diesel fuel as an accelerant, which are really, you know, not the best choice because of the flashback burn that they get.

The other thing that we often see too is scald burn. Scald burns are very common in children for a host of reasons, including ramen noodle burns from scalds. These are easy access for a lot of children. They can be put in the microwave. They're easy to cook. And they're also very easy to spill when they're extremely hot and cause some pretty significant injuries. So, that's what we see very commonly here at UF Health.

Lauren Indelicato: And one thing I wanted to add, another common one that we see is people will often burn their trash, so they don't have to pay for trash pickup. And we see kids that run through hot embers, because it's Florida and they run around in their bare feet. They run across an old fire pit that they thought has been out for a long time, but the embers actually stay hot for five days. And we see lots of foot burns from that mechanism as well.

Melanie Cole: Dr. Larson, can you discuss the reasons for us why children require a specialized approach and resources for burn injury? Help us to understand local and systemic physiologic changes caused by burns so that other providers can best understand the therapeutic options available.  

Dr. Shawn Larson: Again, another great question. We, in the pediatric community, often will say that children are not small adults. And obviously what does happen a lot of times with a pediatric trauma and pediatric burn injury is that people will extrapolate adult treatment and adult responses to trauma and burns.

There's been some great research that's been done lately, but when you get a burn wound, you have a very large, well, potentially a large surface area of injury, and the effects of that injury are not just at the time of injury, but are ongoing. So children will get a number of different physiological responses to them and you need providers, doctors, nurses, and other hospital personnel that are familiar with dealing with children to recognize, you know, how best to treat that physiological response. When a child comes in, you know, the first thing we do is we do something called the advanced trauma life support protocol, which is from the American College of Surgeons. To ensure that there are not other injuries that are involved, we assessed the child from head to toe very quickly and make sure that there are no life-threatening injuries and then initiate that treatment.

Well, the first thing you got to do with a burn wound is to stop the burn. And then the second thing is to try to prevent is secondary injury from the continuing injury going on at the cell level. So what does that mean? Well, you got to get rid of the dead cells and the dead skin. We got to get some treatment on there. And that. When you think about it, the skin is the largest organ in the body and is an important protective barrier for infection. So we have to get that covered, preferably cleaned and sterilized, or at least some sort of antibiotic treatment and then address the special needs of the children. I'll let Lauren kind of talk us through how a child comes through the peds ER and then through the inpatient stay.

Lauren Indelicato: Yeah. So once the kid arrives in the ER, ER attending physicians usually assess the patient. They give us a call right away. So we come down there fairly quickly. We have the burn nurses who are all specialized burn nurses. They come down and, with the collaboration with the ER staff, that patient usually gets a conscious sedation. And then, the burn nurses go ahead and clean up the burns. They debrid them. They apply the dressing that we usually tell them to whether it's an antibiotic ointment or a silver-impregnated pad called Mepilex. The patient kind of recovers down there. We speak to the family and then they usually will get admitted to the floor.

Once they are on the floor, we follow them very closely, whether they're in the pediatric ICU or on the regular floor. We are very involved with the family. We get Child Life involved who helps with medical play and distraction. We have social work involved with all of our patients to help the families kind of work through this traumatic experience as well as help them with dressing supplies when they're discharged. We also have physical therapy and occupational therapists who are also specialized with burn care to work on range of motion and just kind of getting back to normal life. And then, we also have specialized burn nurses who have been trained on how to do pediatric burn care and dressing changes.

Dr. Shawn Larson: Just like to add, taking care of a pediatric burn, there's some basic principles of first aid that are involved. And a lot of providers can obviously take care of the burns, but when you start getting into the bigger burns or the sicker child, what is most important is the team. And that team is a multidisciplinary team that would approach this just like a cancer diagnosis or other type of injury. And having therapists present and the social work as Lauren indicated are incredibly important for making sure that these kids have the best long-term outcomes.

Melanie Cole: Well, thank you both for that. And Lauren, please expand a little bit on that, the importance of how awareness of those long-term physical and emotional outcomes can be enhanced through participation in burn aftercare programs, scar management, occupational and physical therapy, all of these accesses to burn reconstruction and emotional counseling, and peer support. Tell us about the importance of that and how you help at UF Health Shands Hospital.

Lauren Indelicato: Right. So I run the outpatient pediatric burn clinic, which again is another great multidisciplinary clinic. It is myself with specialized burn nurses. We have Child Life who comes up as well, who helps with the distraction for dressing changes. And then, I also have a physical therapist in clinic who does a great job assessing range of motion issues. She also measures for burn garments, which we provide our patients for scar management through grants that we get through the Children's Medical Network as well as the UF Medical Guild. It is an ongoing process. I see them, you know, through their stages of healing. And I usually follow up with them weekly until they are healed. And then I will see them periodically for about every three months for the first year and a half while they get their scars under control. And then after that, once their scars have matured, I will see them yearly for scar checks for several years.

Melanie Cole: Dr. Larson, as we're talking about future research and putting translation into practice, are there some gaps in the evidence-based knowledge that we have? Tell us of any emerging, unique interventions and challenges that you've noted and what you'd like other providers and pediatricians to do to help their patients prevent burns at home.

Dr. Shawn Larson: Again, another excellent question. There are major gaps in the research that's been done, because we don't know all of the different stages depending on the child's age of their physiological response. And that's one thing that our center has been working towards getting some answers by doing translational research. We've also participated in clinical trials for various treatment, novel treatments for burn wounds.

So one of the things that has always bothered me about caring for burn wounds is that many times the main tool that we have for deep burns and big burns is skin grafting. And while that's some pretty awesome technology, it still ends up creating twice the size of the burn wound. For instance, you have a child that comes in with a 10% burn wound that needs skin grafting. Then in order to cover that area of 10%, we've essentially created a 20% wound. And that child is then going to have to undergo a lot of metabolic changes to heal that 20% wound in addition to the burn injury. And so I think, you know, are there ways that we could use stem cell treatments, or by taking a few cells of skin and potentially growing that.

And we've participated in a number of different trials. We were one of the first institutions in the state of Florida to actually use a system by where we grew a patient's skin to graft. We also have participated in some clinical trials to evaluate new or novel ways to treat burn wounds from using, you know, medicines that could be applied to the burn wound to do the debridement process rather than proceeding to the operating room.

Another clinical trial that were participating in or will be participating in is a way of taking a few cells and expanding those cells literally within one-hour period of time and then putting those cells back onto the wounds to allow them to grow the new skin that we need. We've also participated in a-- It wasn't a clinical trial, but it was a compassionate use, which is the FDA allows us to use experimental type treatment under very careful guidance, to basically take some skin samples from a patient and then grow their own skin in a laboratory, and then use that as part of the autografting process.

So one of the things that we do here at our center is to continuously look for new ways to treat children, whether it be with the debridement process or removing of the injured skin, whether it's the autografting process and then even beyond that where we're looking at ways to better manage scars and the longer-term effects of that. You know, for the pediatricians and the folks that would be referring the patients to our center, that's something that I would like them to know. This is an academic process for us. What do I mean by that? You know, we see the problem and then we try to continuously almost every single day of the year get up and come up with a newer and better way to help these kids.

As far as the pediatricians out in the community who are really obviously the frontline providers and an important first line with this is to discuss fire safety at home. Discuss how are the kids getting burned in the community? Well, in our community, it's the use of scald burns. In the rural communities, it's the use of accelerant on fires and open fires. And then as Lauren had pointed out, there's also a large number of people that do fire pits or burn trash, and to make sure that these fires are properly extinguished. So again, prevention is very important and, you know, there is good evidence out there that when the pediatricians and providers get involved in making sure that children are safe, that that really does help to educate parents and children about the various dangers within the home.

Melanie Cole: And Lauren, last word to you. What would you like other providers to take away from this segment and your multidisciplinary approach to pediatric burn management?

Lauren Indelicato: I think just awareness about what we do here. It seems to be like an ever-evolving process that just gets better and better. I've been here a long time and I've personally seen it evolved into the multidisciplinary clinic. We refer patients out as well, if we need, to other specialties, such as pediatric hand plastic surgeons. Sometimes they need some orthopedic help. It just kind of depends on what's best for the patient. We also are starting to get a little more of the psychosocial aspect of things involved, which I think is a huge part of burns that kind of gets ignored as the patient’s kind of go on with their life. So it really is an evolving process that is moving forward in the right direction more and more.

Melanie Cole: Thank you both so much for joining us today. What an informative segment and such an important topic. To refer your patient, please visit UFHealth.org/pediatric surgery to get connected with one of our providers. Or to learn more about other healthcare topics at UF Health Shands Hospital, please visit UFHealth.org/medmatters.

That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.