Paediatric burn injuries are a traumatic event causing significant pain, anxiety and distress at the time of injury and throughout the resulting wound care procedures. Pain and anxiety management not only play a significant role in determining how the child will cope with wound care procedures, but may influence long term pain hypersensitivities and the development of psychological conditions (e.g. acute stress symptoms and post-traumatic stress disorder). Mounting evidence supports links between pain/anxiety/stress and the negative effects these experiences have on wound healing, however no study has delved into investigating these possible links or causal relationships in the area of burns. The aim of this study was to determine if reducing the pain, anxiety and stress of a child during repeated burn wound care procedures (using the multi-modal procedural preparation and distraction Ditto™ intervention), reduced the number of days for burns to re-epithelialise.
A pilot study was carried out to understand the profiles of salivary alpha-amylase and salivary cortisol during burn wound care procedures, to inform the larger study on ideal collection time points to measure these biological markers of stress. Salivary alpha-amylase levels peaked at zero minutes post dressing removal/wound debridement, and salivary cortisol levels peaked a further ten minutes later.
A prospective randomised controlled trial (RCT) was undertaken with children 4-12 years who presented with an acute burn injury for their first dressing change. Participants were randomly assigned to either the (1) Control group (standard preparation and distraction) or (2) Ditto™ intervention group (receiving Ditto™ procedural preparation and Ditto™ distraction). Repeated measures of pain intensity, anxiety, stress and re-epithelialisation were taken at every dressing change until complete re-epithelialisation.
Seventy-seven children (4-12 years) participated in the RCT; 41 in the control group and 36 in the Ditto™ intervention group. Ditto™ procedural preparation and distraction were found to reduce re-epithelialisation by two days (p=0.046) when adjusted for burn depth. An economic evaluation was performed which concluded the Ditto™ intervention to be highly effective against standard practice at a minimal cost for the significant benefits gained. The estimated cost-effectiveness ratio showed a median cost of $64 (interquartile range = $10 - $106) for every one day reduction in days to re-epithelialise when children had access to Ditto™ intervention, over standard practice. The positive gains support the implementation of Ditto™ procedural preparation and distraction intervention during burn wound care.
Factors that contributed towards delaying re-epithelialisation were identified as: burn depth (by laser Doppler imaging), days taken to present to the burn centre, pain levels of children who did not receive the Ditto™ intervention, ethnic origin, flame as the mechanism of injury and total body surface area of the burn. These factors accounted for 69% of variance in the model. Surprisingly, burn injuries on participants from ethnicities of darker skin complexion re-epithelialised 25% faster than participants with a lighter skin complexion (p=0.001). Despite adjustment for burn depth, flame as the mechanism of burn injury was found to delay re-epithelialisation by 39% compared to all other mechanisms (p=0.003).
Salivary alpha-amylase was found to be a better biological measure of stress than salivary cortisol during morning burn clinics. Higher salivary alpha-amylase levels were significantly associated with higher pain scores (p=0.021), receiving no medication (p=0.047), and higher Child Trauma Screening Questionnaire scores (p=0.008) at three months post re-epithelialisation.
Burden of injury encompasses a multitude of psychological and physiological factors for the patient and significant costs to the health care system. Use of the Ditto™ non non-pharmacological intervention as an adjunct to standard practice is a worthwhile intervention minimising days to re-epithelialise at a minimal cost to the health care system.