Domestic burns in neonate are rare in literature. Neonates are high risk for burns because of their thin and fragile skin, fluid overload or dehydration as the fluid balance range is small and immature immune system leading to septicaemia. Neonates are not small adults, owing to their different physiological response makes the management of neonates challenging as the clinical signs are different from the adults and the resuscitation protocols or end points are also different. We present a case of 11 days old neonate, who sustained 51% scald burns when the hot water bag being used by her mother accidentally burst, the youngest reported case of domestic scald burns with such high percentage. The baby was managed by fluid resuscitation, antibiotics, dressings, ventilatory support for septicaemia and subsequently homograft application. The neonate was discharged with completely healed areas after 35 days of burns and is on regular follow up and no complications have been observed.
KEY WORDS: Accidental, neonate, scald burns
The illustration of domestic neonatal accidental scald burns is rare in literature. Neonates form a high-risk age group for consideration of burns due to the rarity of the burns in this age group, thinness of the skin, immature immune system, difficulties in fluid management, the high probability of these patients to land up in septicemia, and the covert signs and symptoms that need strict vigilance, paucity of donor sites for wound coverage, and the long-term complications.
We present a case of domestic neonatal scald burns in an 11-day-old neonate, who sustained major scald burns in her lower limbs, trunk, and both upper extremities when the hot water bag, being used by her mother for shoulder pain accidentally burst while feeding the baby. The child was immediately rushed to a nearby hospital where primary fluid resuscitation was provided by a pediatrician and referred to higher center for definitive management. The child arrived at our institution within 3 h of sustaining burns.
The neonate was alert and excessively crying on arrival. Vital signs were within normal limit as determined by the neonatologist involved in management. Burn assessment for total body surface area (TBSA) was done using Lund and Browder Chart and was found to be 51%. At preliminary assessment, we found around half, that is, 50% of the involved area to be second degree superficial and rest second degree deep burns. A peripheral venous access was obtained and samples for routine blood investigation and swabs were taken. Fluid calculation was done according to Galveston’s formula; dextrose containing solutions were added to the regimen as per the need. The target urine output of 1.5-2 mL/kg/h was strictly monitored and fluid adjustments made accordingly. For prevention of hypothermia, the neonate was dressed with occlusive dressings and covered by a blanket, and hourly monitoring of rectal temperature was done in a pediatric intensive care unit (ICU). Antibiotics and analgesics were started according to the body weight after consultation with the neonatologist. Strict input-output charting was maintained; vital parameters of heart rate, pulse, temperature, and pulse-oximetry were monitored hourly. The urine output too was monitored by weighing the diapers every hour. The serum electrolytes were monitored daily [Figure 1].
On the second day of admission, following resuscitation, the patient was taken onto operative room and under general anesthesia, the burn wound was cleaned with normal saline and polyurethane sheets were applied and dressed with sterile paraffin tulle gras.
The vitals of the patient remained stable for 3 days. During the course of treatment, the mother was constantly encouraged to breastfeed the baby. On the 4th day, the baby refused breastfeed, developed hypothermia, and urine output decreased. With suspicion of septicemia, the patient was immediately assessed by neonatologist and was placed on ventilator support for tachypnea and deterioration of vital parameters. A central venous catheter was placed and antibiotics were changed. Antifungals were added to the treatment, all routine investigations were sent including C-reactive protein, blood culture, and swab for culture and sensitivity from the wound. The patient was fed with expressed milk from the mother through a nasogastric tube. The patient improved after 2 days of intensive management and was weaned from the ventilator on the 7th day of admission.
During this period, there was no soakage or foul smell from the dressed wound site to indicate that the dressings need to be changed immediately. Antibiotics were changed after obtaining reports of culture sensitivity.
Dressings were changed on the 8th day and it was found that majority burns had healed except for about 10% over the abdomen and lower limbs. Polyurathane sheets were reapplied over rest of the areas and dressings were placed. Subsequently, dressings were done on every alternate day continuing the general care and nutrition of the baby [Figures 2 and 3].
The wound showed signs of healing, but around 10% of raw area remained over the lower limbs and anterior abdominal wall after 2 weeks that was considered for definitive coverage by operative procedure. The father was counselled for homograft donation for the child as the mother had herself sustained 10% scald burns over her back, gluteal region, and thighs from the accident, and the donor areas were unavailable for the neonate. On the 22nd day of admission, after normalization of all parameters of the baby and preparation of the wound bed by dressings, homograft was applied for the remaining raw areas. The graft-take was complete and the wounds healed completely. Subsequently, the neonate was discharged with advice for regular follow-up [Figure 4].
Department of Plastic Surgery and Burns, Smt. NHL Municipal Medical College, Sheth Vadilal Sarabhai Hospital, Ahmedabad, Gujarat, India1Consultant Paediatrician, Ahmedabad, Gujarat, India
Address for correspondence: Dr. Vijay Y. Bhatia, Burns, Plastic and Cosmetic Surgery Hospital, Ground floor, Sunder Gopal Complex, Ambawadi Circle, Ahmedabad – 380 006, Gujarat, India. E-mail: moc.liamg@101aitahb
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