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hamsters, chipmunks, voles, moles, rabbits, and hares almost never require rabies postexposure pro-phylaxis. Therefore, the treatment of all suspect wounds should include immediate local wound care, tetanus prophylaxis consideration, and rabies post-exposure prophylaxis.

Although the HDCV has been proven safe, immu-nologically potent, and efficacious, various adverse reactions have been reported over the years. How-ever, no deaths have been attributed to the vaccine. Approximately 50% to 80% of the HDCV recipi-ents report local reactions including pain, erythema, swelling, and itching at the injection site. Another 20% of patients have reported mild to severe sys-temic reactions including headache, nausea, vomit-ing, fever, malaise, abdominal pain, myalgias, dizzi-ness, local or general lymphadenopathy, urticaria, and anaphylaxis.8,9In addition, four cases of

neuro-paralytic reactions have been reported after the ad-ministration of the vaccine. Three of those patients exhibited a Guillain–Barre´-type illness and recovered fully.

Adverse reactions to vaccines (such as tetanus, diphtheria, pertussis toxoids, measles, mumps, ru-bella, oral polio, and inactivated polio) are reportable by federal law to the Vaccine Adverse Event Report-ing System. Reports of clinically significant adverse reactions occurring after the administration of any other vaccine licensed in the United States are strongly encouraged. The Centers for Disease Con-trol and Prevention and the Food and Drug Admin-istration review all data reported to detect unusual epidemiologic associations, adequate product label-ing, and trends of individual vaccine manufacturers and vaccine lots.

The possibility of another agent, such as chloro-quine phosphate, having caused this seizure was considered and rejected for the following reasons. First, adverse reactions to chloroquine phosphate have included constitutional symptoms, anorexia, abdominal pain, mild headaches, hypotension, pru-ritus, hair loss, hemolytic anemia, leukopenia, thrombocytopenia, skin eruptions, vision changes, convulsions, and rare electrocardiographic changes. Second, the patient was asymptomatic on admission to the emergency department. Third, the administra-tion of this patient’s medicaadministra-tion was monitored closely by his parents and overdosage was unlikely. In fact, the patient took his final dose the day before admission. Finally, results of the patient’s electrocar-diography and complete blood count were normal and did not reveal blood dyscrasias or Q-T segment prolongation as seen in chloroquine toxicity.

The seizure experienced by this patient after the administration of the HDCV and half of the rabies immune globulin (human) appears to demonstrate a strong causal relationship. However, it is not possi-ble to determine clearly whether the HDCV or the rabies immune globulin caused this seizure. Addi-tional correlation was not possible because of the strong and justified concerns of the parents. Al-though the mechanism for this seizure is not under-stood and no other such reaction has been reported,

one must not delay rabies postexposure prophylaxis because of such a rare adverse reaction.

Michael D. Mortiere, BS, PA-C

Angelo L. Falcone, MD

Department of Emergency Medicine Fairfax Hospital

Falls Church, VA 22046

REFERENCES

1. Centers for Disease Control and Prevention. Systemic allergic reactions following immunization with human diploid cell rabies vaccine. MMWR. 1984;33:185–187

2. Bernard KW, Smith PW, Kader FJ, et al. Neuroparalytic illness and human diploid cell rabies vaccine. JAMA. 1982;248:3136 –3138 3. Boe E, Nylan H. Guillain–Barre´ syndrome after vaccination with human

diploid cell rabies vaccine. Scand J Infect Dis. 1980;12:231–232 4. Knittel T, Ramadori G, Mayet WJ, et al. Guillain–Barre´ syndrome and

human diploid cell rabies vaccine. Lancet. 1989;1:1334 –1335. Letter 5. Veterinary Public Health Unit. World Survey of Rabies 27. Geneva,

Switzerland: World Health Organization; 1993

6. World Health Organization. Global health situation. IV. Selected infec-tions and parasitic diseases due to identified organisms. Weekly Epide-miol Rec. 1993;7:43– 44

7. Fishbein DB, Bernard KW. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 4th ed. New York, NY: Churchill Livingstone; 1995;2:1527–1543

8. Centers for Disease Control and Prevention. Recommendations of the Immunization Practices Advisory Committee (ACIP). Rabies preven-tion—United States. MMWR. 1984;33:393– 402, 407– 408

9. Leads from the MMWR. Systemic allergic reactions following immuni-zation with HDCV. JAMA. 1984;251:2194 –2195

Burns in Children Younger Than

Two Years of Age: An Experience

With 200 Consecutive Admissions

C

hildren,2 years of age are at increased risk of sustaining burn injury and are considered more difficult to manage than older children. We performed this data collection to facilitate better understanding of the clinical characteristics of this unique subpopulation of injured children.

MATERIALS AND METHODS

We collected data on 200 consecutive children,24 months of age who required admission to a regional pediatric facility be-tween September 1, 1991 and August 22, 1993 for management of acute burns. The Shriners Burns Institute is a 30-bed regional facility that is verified as a pediatric burn center by the American College of Surgeons and American Burn Association Burn Center verification process. It provides comprehensive acute and long-term free care to children with burn injuries. We have a very busy outpatient clinic and commonly manage small burns in the out-patient setting; however, children managed as outout-patients were not included in this review. Criteria for outpatient management include: 1) a burn that is,15% of the body surface so that fluid resuscitation is not required, 2) the ability to take fluids by mouth (excludes children with significant perioral burns), 3) no

sugges-This work was presented at the 29th Annual Meeting of the American Burn Association in New York, NY, March 1997.

Received for publication Dec 12, 1996; accepted Apr 7, 1997.

Reprint requests to (R.L.S.) Shriners Burns Institute, 51 Blossom St, Boston, MA 02114.

PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad-emy of Pediatrics.

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tion of possible airway involvement (no suggestion of hot liquid aspiration), 4) reliable family with transportation resources that will allow for clinic visits, and 5) no question of abuse.

Children were managed uniformly, emphasizing prompt wound excision and closure.1Children with small (,10% of the body sur-face) scald burns were treated with topical therapy with dressing changes generally once daily. When, after 3 to 7 days of such therapy, a full-thickness component was clearly evident on physical exami-nation, they underwent surgery for excision and autografting of this component. Clean superficial wounds were generally covered with porcine xenograft (Mediskin, Brennen Medical, St Paul, MN) until healed. Children with obvious full-thickness injury, particularly those with wounds.15% of the body surface, were promptly oper-ated, generally within 48 hours of injury. When donor sites were insufficient to provide immediate definitive closure of excised wounds, human allograft was placed. This was removed and re-placed with autograft from donor sites harvested previously as soon as the wounds healed, generally within 7 to 10 days of initial harvest. Anabolic agents were not used. Cultured keratinocytes were used in two children with burns.90% of the body surface to provide partial wound closure.2Children who required mechanical ventilatory sup-port for airway protection or respiratory failure had their inflating pressures and oxygen concentrations capped at 40 cm H2O and .60% Fio2, respectively, except in exceptional circumstances, as described

previously.3Central venous catheters were replaced by guide wire or rotated to a new site every 7 days.4Nutritional support was empha-sized, and nasogastric tube feedings were the mainstay of therapy, parenteral support being reserved for those children intolerant of nasogastric feeds or who required frequent trips to the operating room. Results are presented as mean6standard deviation.

RESULTS

These 200 children had an average age of 13.4 6 5.5 months (range, 1 to 24 months), average weight of 10.562.2 kg (range, 4.2 to 16.5 kg), and average burn size of 10.1613.8% of the body surface (range, 0.1% to 95%). There were 122 boys and 78 girls. There were 127 children with burns involving,10% of the body surface, 44 with burns involving 10% to 19%, 24 with burns involving 20% to 49%, and 5 with injuries involving.50%. There were 122 Caucasian, 22 His-panic, 32 Black, and 10 Asian children; the data were not recorded for the remainder. Significant medical history included thalassemia (1 child), inguinal her-nia (2 children), pyloric stenosis (2 children), long bone fracture (2 children), cardiac defect (2 children), meningitis (1 child), muscular dystrophy (1 child), Erb’s palsy (1 child), intussusception (1 child), pre-maturity (3 children), retinopathy (1 child), intraven-tricular hemorrhage (1 child), febrile seizures (2 chil-dren), previous burns (1 child), asthma (10 chilchil-dren), and otitis media (17 children).

Mechanisms of injury included flame (11 patients, 5.5%); tub scald (25 patients, 12.5%); spilled scald (109 patients, 54.5%); contact, particularly with cloth-ing or curlcloth-ing irons (47 patients, 23.5%); chemical (1 patient, 0.5%), high voltage (1 patient, 0.5%); and other (5 patients, 2.5%). Central venous catheters were used in 27 (13.5%) of the children, arterial lines in 9 (4.5%), bladder catheters in 37 (18.5%), endotra-cheal tubes in 13 (6.5%), and tracheostomy in 1 (0.5%). Total parenteral nutrition was used in 12 children (6%), and tube feedings in 28 (14%). Thir-teen children (6.5%) required mechanical ventilatory support. Seven had inhalation injury, and 3 were suspected to have aspirated hot liquid. There were 192 operations required: 10 children (5%) had al-lograft used, and 2 children (1%) with burns of 90% and 95% had cultured autologous epithelium used.

Porcine xenograft was used on partial thickness burns in 67 children (33.5%). Serious nosocomial in-fectious complications included pneumonia in 6 chil-dren (3%), urinary tract infection in 4 (2%), Gram-positive bacteremia in 7 (3.5%), Gram-negative bacteremia in 2 (1%), and candidemia in 2 (1%).

Children were hospitalized an average of 15.2 6 19.6 days (range, 1 to 174), which represented 4.06 8.7 (median, 1.7 days; range, 0.17 to 100) days per percent body surface burn. However, this figure de-creased sharply as burn size inde-creased, with the 73 children with burns$10% (average 21616% of the body surface) hospitalized for 1.4 6 2.0 days per percent body surface burn and those 29 children with injuries involving$20% of the body surface (average 34620% of the body surface) hospitalized for 1.16 0.8 days per percent body surface burn. Our facility also provides burn rehabilitation and these hospital days included all rehabilitation stays, with only one child being transferred to a rehabilitation hospital closer to his home in another state.

Injuries were filed with state social service agen-cies in 37 cases (18.5%), and the outcome of these filings was home with services in 17 cases (45.9%), foster care in 6 cases (16.2%), home with investiga-tion of alternate care giver in 5 cases (13.5%), home with case open in 4 cases (10.8%), and no action in 4 cases (10.8%). A filed injury occurred in a child al-ready in state custody in 1 case (2.7%). No child was readmitted with a second burn injury, and we are aware of no admissions for other injuries. All chil-dren were discharged home except for those sent to foster care and one child who was transferred to a rehabilitation facility. There were no deaths.

DISCUSSION

Children ,2 years of age are at increased risk of sustaining burn injury,5and in many respects are more

difficult to manage than older children. Several authors have emphasized the increased morbidity and mortal-ity associated with burns in this age group. Morrow et al6 reported that increasing burn size and decreasing

age were statistically significant predictors of mortality by logistic regression analysis. Erickson et al7reported

that children,48 months of age had more than twice the mortality rate of older children and adults with equivalent injuries. Our data seem to be at variance with this experience. However, this paper is not an effort to prove that any one approach to burn care is superior. Specifically, although we do practice early excision and closure of full-thickness burns, these de-scriptive data cannot be used to show that this policy will decrease mortality or shorten hospital stay.

Conclusions that we have drawn from this data collection include the following: 1) significant comor-bidities are common in burned young children; 2) length of hospital stay is;1 day per percent burn in those children with large injuries (including rehabil-itation days); 3) the most common mechanisms of injury involve scalding by spill or immersion in hot liquid and by contact with clothing or curling irons; it is here that prevention efforts should focus; 4) almost 20% of cases are referred to state social

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vices for investigation in this age group, and almost 20% of these children were discharged to foster care; 5) invasive support devices can be used in children with serious burns with an acceptably low incidence of infectious complications; and 6) children ,24 months of age can be expected to survive serious burns when managed in an organized manner em-phasizing prompt wound closure.

Robert L. Sheridan, MD, FAAP*‡§

Colleen M. Ryan, MD*‡§

Lisa M. Petras, RN*

Martha K. Lydon, RN*

Joan M. Weber, BSN, CIC*

Ronald G. Tompkins,MD, ScD*‡§

*Shriners Burns Institute Boston, MA 02114

‡Department of Surgery Massachusetts General Hospital Boston, MA 02114

§Department of Surgery Harvard Medical School Boston, MA 02115

ACKNOWLEDGMENT

This work was supported by the Shriners Hospitals for Children.

REFERENCES

1. Sheridan RL, Tompkins RG, Burke JF. Management of burn wounds with prompt excision and immediate closure. J Intensive Care Med. 1994;9:6 –19

2. Sheridan RL, Tompkins RG. Cultured autologous epithelium in patients with burns of ninety percent or more of the body surface. J Trauma. 1995;38:48 –50

3. Sheridan RL, Kacmarek RM, McEttrick MM, et al. Permissive hypercapnia as a ventilatory strategy in burned children: effect on barotrauma, pneumonia, and mortality. J Trauma. 1995;39: 854 – 859

4. Sheridan RL, Weber JM, Peterson HF, Tompkins RG. Central venous catheter sepsis with weekly catheter change in paediatric burn patients: an analysis of 221 catheters. Burns. 1995;21:127–129

5. Erdmann TC, Feldman KW, Rivara FP, Heimbach DM, Wall HA. Tap water burn prevention: the effect of legislation. Pediatrics. 1991;88: 572–577

6. Morrow SE, Smith DL, Cairns BA, Howell PD, Nakayama DK, Peterson HD. Etiology and outcome of pediatric burns. J Pediatr Surg. 1996;31: 329 –333

7. Erickson EJ, Merrell SW, Saffle JR, Sullivan JJ. Differences in mortality from thermal injury between pediatric and adult patients. J Pediatr Surg. 1991;26:821– 825

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DOI: 10.1542/peds.100.4.721

1997;100;721

Pediatrics

Weber, Ronald G. Tompkins and MD, ScD

Robert L. Sheridan, Colleen M. Ryan, Lisa M. Petras, Martha K. Lydon, Joan M.

Consecutive Admissions

Burns in Children Younger Than Two Years of Age: An Experience With 200

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DOI: 10.1542/peds.100.4.721

1997;100;721

Pediatrics

Weber, Ronald G. Tompkins and MD, ScD

Robert L. Sheridan, Colleen M. Ryan, Lisa M. Petras, Martha K. Lydon, Joan M.

Consecutive Admissions

Burns in Children Younger Than Two Years of Age: An Experience With 200

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