Sheridan RL, Hinson MI, Liang MH, Nackel AF, Schoenfeld DA, Ryan CM, Mulligan JL, Tompkins RG. Long-term Outcome of Children Surviving Massive Burns. JAMA. 2000;283(1):69–73. doi:10.1001/jama.283.1.69
Author Affiliations: Shriners Burns Hospital for Children (Drs Sheridan, Nackel, Ryan, and Tompkins and Mss Hinson and Mulligan), Department of Surgery, Harvard Medical School and Massachusetts General Hospital (Drs Sheridan, Ryan, and Tompkins), Department of Medicine, Harvard Medical School, Brigham & Women's Hospital (Dr Liang), and the Departments of Health Policy and Management (Dr Liang) and Biostatistics (Dr Schoenfeld), Harvard School of Public Health, Boston, Mass.
Context Major advances in treatment of burn injuries in the last 20 years have
made it possible to save the lives of children with massive burns, but whether
their survival comes at the cost of impaired quality of life is unknown.
Objective To investigate the long-term quality of life in children who have survived
Design and Setting Retrospective, cross-sectional study conducted in a regional pediatric
Patients Eighty subjects who were younger than 18 years at the time of injury,
who survived massive burns involving ≥70% of the body surface, and who
were admitted to the burn center between 1969 and 1992 were evaluated an average
(SD) of 14.7 (6.0) years after injury.
Main Outcome Measures Short Form 36 (SF-36) scores of the 60 patients aged at least 14 years
were compared with national norms and the impact of clinical variables on
individual domain scores was assessed.
Results The SF-36 domain scores of the study patients, who had survived massive
burns at a mean (SD) age of 8.8 (5.5) years, were generally similar to the
normal population). However, 15% and 20% of the burn patients had scores in
the physical functioning and physical role domains, respectively, that were
more than 2 SDs below the relevant norm, indicating that a few patients had
continuing serious physical disability. Better functional status of the family
predicted a higher score in physical role (P = .04).
The child's early reintegration with preburn activities predicted higher scores
in general health (P = .03), physical functioning
(P = .003), and physical role (P = .01). Children followed up consistently in the multidisciplinary
burn clinic for 2 years had higher physical functioning (P = .04).
Conclusions In this study, while some children surviving severe burns had lingering
physical disability, most had a satisfying quality of life. Comprehensive
burn care that included experienced multidisciplinary aftercare played an
important role in recovery.
The successful treatment of massive burn injuries is one of the major
advances in trauma care of the last 20 years. Before the 1970s, a burn involving
more than one third of the body surface was almost always fatal; the few patients
who did not die from burn shock during the first few postinjury days died
from wound sepsis in the subsequent weeks.1
Improved fluid and electrolyte management and critical care combined with
early wound excision and closure2,3
have had a profound impact on the natural history of such injuries.4- 6 Although it has become
possible to save the lives of massively burned children,7
the wisdom of doing so has become a health policy and ethical question.
Although almost 1 million American children are burned annually, only
approximately 3% have massive injuries, defined as involving more than 70%
of the body surface. Approximately 75% of those with massive injuries are
managed in specialized multidisciplinary burn centers and the remainder are
cared for in critical care units in pediatric general hospitals. Optimal management
of severely burned persons is enormously expensive8
and, even after survival is ensured, may require protracted surgical, medical,
psychological, and rehabilitation interventions for many years.9,10
It has been argued that the results are so dismal that these children should
be allowed to "die with dignity."11 The impact
of comprehensive burn center management on long-term outcomes is unknown.12
The existent data on children surviving massive burns are compromised
by short-term follow-up, small sample size, selection bias, lack of standardized
outcome measures, high dropout or nonparticipation rates, and lack of injury
severity adjustments.13 Only 1 long-term outcome
study of children with massive burns has been published.14
In that 4-year follow-up study of 12 children, the global quality of life
was believed to be acceptable but was not objectively defined. Although it
is commonly believed that injury size is the principal determinant of outcome
quality,14,15 social and emotional
factors are also thought to have a major influence.16- 18
In this study, we evaluate the long-term outcome of all children managed at
a single dedicated burn center who survived massive burn injuries.
All surviving patients whose initial treatment was at the Shriners Burn
Hospital for Children in Boston, Mass, for thermal injuries involving 70%
or more of the body surface who were admitted between January 1, 1969, and
December 31, 1992, were identified by the hospital registry. Inclusion criteria
included age younger than 18 years at the time of admission, fluency in English,
and residence within North America. All acute burn care was provided at the
Shriners Burns Hospital in Boston, a 30-bed facility certified as a burn center
by the American College of Surgeons and American Burn Association that provides
comprehensive free care to children with burn injury of all degrees of severity.
All care is provided at no cost to families or insurance carriers.
Surviving children are also offered continued participation in a program
of multidisciplinary aftercare until age 21 years. This program, managed in
the burn clinic and also offered at no cost, consists of coordinated family
services, reconstructive surgery, and rehabilitation therapy. The Shriners
organization is generally able to provide funds for children to travel back
and forth from home to the burn center as needed to undergo evaluation and
surgery. Routine postoperative physical therapy is provided by therapists
near the patient's home under supervision of burn center–based therapists.
The study was approved by the Subcommittee for Human Studies at Massachusetts
General Hospital, Boston, and by the Shriners Hospitals for Children.
There were 147 children who met study criteria. Eighty (54%) of these
children were discharged alive. The following information was obtained from
each patient's hospital and outpatient records: patient demographics, date
of injury, date of hospital admission, date of hospital discharge, presence
of inhalation injury, extent of burn injury, family income, employment status
of the parent(s) or guardian, enrollment in public assistance programs at
the time of admission, an estimate of family functional status at the time
of injury, the child's early reintegration with preinjury (school or preschool)
activities after discharge, and the consistency of follow-up in the multidisciplinary
burn clinic after discharge. A family was defined as functional if there was stable housing (not a shelter or transient housing),
support of extended family, no parental substance abuse, no family involvement
in state child protective services programs and the child was in school if
of appropriate age. Children were deemed to have undergone successful early
reintegration with preburn activities if they had returned to school or preschool
and the family unit remained stable 4 months after discharge. This time point
was chosen because it was consistently available. Children were considered
to have had consistent clinic visits if they were seen at least 4 times per
year for at least 2 years after discharge in the multidisciplinary burn clinic.
Between September 1995 and June 1997, patients or their families were
contacted and 2 structured telephone interviews were conducted by 1 trained
interviewer. The goal of the first interview was to establish contact, elicit
the patient's general circumstances, and obtain informed consent for participation
in the study. During the second interview, the Short Form 36 (SF-36) was administered.
No widely used and validated quality-of-life instrument exists for burn patients,19 but the SF-36 is a validated instrument that meets
the requirements of our study. The SF-36 is a multidimensional, health-related
quality-of-life measurement tool of proven reliability and validity in a number
of chronic disease and injury disorders, and has norms for the US population.20- 23 It
has also been widely translated and validated in several non–North American
It fulfills the requirement of measuring global reintegration and socialization28,29 as characterized by 8 domains: general
health, physical functioning, social functioning, physical role, emotional
role, mental health, energy/vitality, and bodily pain. The general health
domain provides a measure of self-perceived overall wellness. Physical functioning
items examine specific aspects of function, such as kneeling, bending, and
walking. The social functioning domain asks about social activities and the
impact of physical or emotional health on relationships. Physical role questions
attempt to examine how physical disabilities limit usual activities such as
work. Emotional role questions examine how emotional disabilities limit usual
activities. Mental health items examine anxiety, depression, and psychological
well-being. Energy/vitality items measure energy level and fatigue. Bodily
pain items look at the intensity and extent of chronic discomfort.
At the initial interview, data were collected on age, education, work,
living situation, significant others, children, and overall adjustment to
life since injury. The SF-36 was administered to all patients aged 14 years
and older at the second telephone interview, after the return of a signed
informed consent form. Eight patients were younger than 14 years, and these
subjects' parents participated in the interview. Domain scores for these 8
patients were compared with scores for those aged at least 14 years using
the t test for normally distributed outcomes and
the Mann-Whitney U test for outcomes that were not
normally distributed. Eight patients chose not to complete the SF-36, and
demographic information was compared between this group and those who did
complete the study using the t test for continuous
variables and χ2 analysis for categorical variables. Three
mentally handicapped subjects were interviewed directly, in the company of
family members. The mean (SD) follow-up period (date of initial discharge
to date of evaluation) for the 68 patients who completed the SF-36 was 14.7
(6.0) years (range, 4-26 years).
Standardized SF-36 scores were calculated based on the general US population.
The standardized score (or z score) is a measure
of how many SD units above or below the US population mean a value falls,
given that patient's sex and age group. Age- and sex-specific norms were available
for the age groups of 18 to 24 years, 25 to 34 years, and 35 to 44 years.30 For this analysis, the 60 study patients aged at
least 14 years were analyzed. Those aged 14 to 17 years were standardized
with norms for the 18- to 24-year age group. The 8 children younger than 14
years were excluded from this analysis. Since the standardized scores for
the test domains were not normally distributed, the analysis was done using
the Wilcoxon signed rank test.
A statistical analysis was done to assess the impact of important variables
on SF-36 scores. These variables included age at interview, age at burn, sex,
burn size, length of hospital stay, time since injury, need for public assistance,
income level above or below the poverty level (defined by the US Census Bureau
median income for a 4-person family, specific to the state and year of injury),
family functional status at the time of injury, the child's reintegration
with preburn activities, and consistency of the child's follow-up in the multidisciplinary
burn clinic. The t test was used for the dichotomous
variables and the Mann-Whitney U test for cases in
which the scores were not normally distributed. Pearson correlation coefficients
were calculated for continuous variables and Spearman correlation coefficients
for non–normally distributed outcomes. The statistical package SPSS
Version 7.0 (SPSS Inc, Chicago, Ill) was used for all analyses.
Of the 80 surviving children, 4 (5%) have died. One patient died 7 years
after discharge of a potential suicide, 1 died 14 years after discharge from
a drive-by shooting, 1 died 12 years after discharge from anoxic brain injury
occurring at the time of the acute burn injury, and 1 patient died 2 years
after discharge from congenital cardiomyopathy. The cause of the suicide is
not known, but it is possible that it was caused by depression related to
Descriptive statistics are presented in Table 1. The complexity and severity of the injuries are reflected
in the average (SD) length of stay of 150 (76) days. Length of stay was strongly
influenced by the presence of inhalation injury, with the average (SD) length
of stay of the 59 children with inhalation injuries equal to 170 (76) days
vs 95 (41) days for 21 children without inhalation injuries (P<.001).
Social and family statistics are also presented in Table 1. Although income information could not be obtained for 6
children, 22 (28%) of the remaining families were receiving public assistance
at the time of the injury, 32 (43%) had an annual family income below the
poverty level, 37 (50%) had income between the poverty level and the median,
and only 5 (7%) had income at or above the national median for the year of
their injury and state of residence. There was at least 1 working parent in
76% of the families.
At the time of the follow-up interview, 27 (36%) of the patients were
currently full-time students; 27 (36%) were gainfully employed; 1 (1%) was
in prison; and 6 (8%) were full-time homemakers. Three patients (4%) were
mentally handicapped and living at home assisted by their family but were
able to perform activities of daily living. The etiology of the handicaps
was probably secondary to retardation that preceded the injury in 1 child
and secondary to anoxia occurring at the time of burn in the remaining 2.
Twelve patients (16%) were unemployed and receiving public assistance but
living independently or at home. Of these 12 patients, 8 reported problems
with chemical or alcohol dependence. Of those 33 patients aged 25 years or
older, 22 (67%) had spouses or significant others and 40% had been or were
currently married. From the entire group, 33 children had been born.
To assess potential response bias, the 8 patients who chose not to complete
the SF-36 were compared with those who completed the study. There was no difference
in patient or family demographics. The 8 patients younger than 14 years were
compared with those aged at least 14 years using the Mann-Whitney U test and were different in 3 areas: higher energy scores (median
score, 82.5 vs 65.0; P = .048), lower physical functioning
(median score, 52.5 vs 92.5; P = .001), and lower
physical role (median, 75.0 vs 100.0; P = .03). The
difference in energy scores is probably related to the younger age of the
group aged less than 14 years, and the lower physical function scores may
be due to the shorter elapsed time since injury that they had not completed
A standardized SF-36 score (z score) of 0 indicates
that the individual's score does not differ from the US population norm for
their age and sex group. The standardized SF-36 domain scores of the burn
patients were not different than the normal population using the Wilcoxon
signed rank test, which would be sensitive to shifts near the center of the
distribution, except for a slightly better score in the mental health domain
(P = .02), which we could not explain (Table 2). However, 15% and 20% of the burn patients had scores in
the physical functioning and physical role domains, respectively, more than
2 SDs below the relevant norm, indicating that a few patients had continuing
serious physical disability.
The impact of important variables on SF-36 scores is presented in Table 3. Increasing burn size correlated
with poorer physical functioning (P = .04). Increased
time since injury predicted better scores in emotional role (P = .003). Female subjects scored higher than male subjects in general
health (P = .02), physical functioning (P = .02), and physical role (P = .001). Male
subjects scored higher on emotional role (P = .04).
Younger patients scored better on energy (P = .009)
and worse on emotional role (P = .001).
Three variables that might be influenced by a coordinated burn aftercare
program had a significant correlation with domain scores: family functional
status, early reintegration, and consistent clinic visits. The functional
status of the family predicted a higher score in physical role (P = .04). The child's return to preburn activities 4 months after discharge
predicted higher scores in general health (P = .03),
physical functioning (P = .003), and physical role
(P = .01). Those children who were followed up consistently
in the multidisciplinary burn clinic for 2 years had higher physical functioning
(P = .04). Length of hospital stay and age at injury
were not statistically significant factors.
This is the first description, to our knowledge, of long-term outcomes
in survivors of massive pediatric burns. It is a unique and nearly complete
cohort from 1 unit describing long-term outcome using a well-validated quality-of-life
measure. These data show that most such children have a quality of life comparable
with the age-matched general population. Other important findings were the
favorable impact of a functional family, early reintegration with preburn
activities, and consistent follow-up in a multidisciplinary burn clinic.
Our data support the strong clinical impression that a supportive family
is of enormous benefit to severely injured children. Burns injure families,
not just individuals.31,32 Because
a child's outcome is so significantly affected by the degree of family function,
it is important that family services be an integral part of acute management
Although early return to preburn activities was a powerful predictor
of a favorable outcome, those who were successful in this area may have been
those with less devastating injuries. However, this finding seems to support
the benefit of directed efforts to reintegrate children with school and other
age-appropriate activities as soon as possible after discharge.
Consistent follow-up in the multidisciplinary burn clinic was a predictor
of better long-term results, although it seemed to select those with more
serious injuries. We interpret this as demonstrating the importance of experienced
multidisciplinary aftercare with coordinated physical and occupational therapy,
scar management, reconstructive surgery, and family services on the end result.
Participation in such a program also provides support through the relationships
that develop among families dealing with similar problems as they meet and
interact during visits to the burn center.
Some potential limitations of this study require comment. The SF-36
is a generic test that does not have disease-specific questions; particularly,
it does not directly measure quality of life associated with physical appearance.
Thus, we were not able to compare burn patients with unaffected individuals
in this important area. However, to the degree that appearance affects psychological
state, these effects are captured by the instruments' mood questions. Second,
although we found that increasing burn size was associated with worse physical
function scores, we were not able to demonstrate a specific impact of facial
or hand burns because virtually all children had injury to these areas. Third,
although the sample is nearly complete, the small numbers of subjects in certain
subsets and the wide range of ages represented may preclude firm conclusions.
Fourth, our measures of a functional family and early reintegration with preburn
activities are imprecise and should be refined in future studies. Finally,
the study involves patients from only 1 center—the population was mostly
white and low income. The generalizability to other samples remains to be
Children who survive massive burns will have major cosmetic and functional
impairments that can never be completely corrected. However, these data show
that treatment of massively burned children is not routinely followed by poor
quality of life. Although massively burned children cannot be returned to
their preinjury appearance and function, high-quality acute care combined
with skillful multidisciplinary aftercare and family support can produce satisfying
long-term outcomes for children with massive burns.