burns 49 (2023) 1311–1320

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

Evaluating effects of burn injury characteristics on

quality of life in pediatric burn patients and
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caregivers

Kelli N. Patterson a, Tariku J. Beyene a,f,g, Katherine Lehman b,

Sarah N. VerLee c, Dana Schwartz d,e, Renata Fabia d,e,
⁎
Rajan K. Thakkar d,e,
a
Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital,
Columbus, OH, USA
b
Ohio State University College of Medicine, Columbus, OH, USA
c
Division of Pediatric Psychology and Neuropsychology, Nationwide Children’s Hospital, Columbus, OH, USA
d
Division of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, USA
e
Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital,
Columbus, OH, USA
f
Veteran Affairs Palo Alto Health System (VAPAHCS), Palo Alto, CA, USA,
g
Stanford University School of Medicine, Stanford, CA, USA

a rt i cl e in fo ab strac t

Article history: Objectives: The purpose of this study was to evaluate pediatric burn patients’ and care­
Accepted 24 January 2023 givers’ quality of life (QoL), while identifying clinical characteristics correlated with psy­
chological stress.
Keywords: Methods: Pediatric burn patients at an ABA-verified institution from November 2019-
Pediatrics January 2021 were included. Caregivers of patients 0–4 years completed the Infant’s
Child Dermatology QoL Index (IDQOL). Patients > 4–16 years completed the Children’s
Burns Dermatology Life Quality Index (CDLQI). The Short Post-Traumatic Stress Disorder Rating
Psychology Interview (SPRINT) measured caregivers’ stress. Generalized linear mixed models eval­
Wounds and injuries uated associations between assessment scores and burn characteristics.
Results: Overall, 27.3% (39/143) of IDQOL and 53.1.% (41/96) of CDLQI scores indicated that
patients’ burns caused moderate to extremely large effects on QoL. In caregivers, 4.5% (7/
159) scored > 14 on the SPRINT, warranting further PTSD evaluation. For the IDQOL, each
additional 1% TBSA burn was associated with a 2.75-point increase (p = 0.05), and patients
sustaining 2nd degree deep partial thickness burns scored an average of 3.3 points higher

Abbreviations: QoL, quality of life; ABA, American Burn Association; PIQIC, Pediatric Injury Quality Improvement Collaborative; IDQOL,
Infant’s Dermatology Quality of Life Index; CDLQI, Children’s Dermatology Life Quality Index; SPRINT, Short Post-Traumatic Stress
Disorder Rating Interview; TBSA, total body surface area; LOS, length of stay; IQR, interquartile range; SD, standard deviation
⁎
Correspondence to: Nationwide Children’s Hospital, Department of Pediatric Surgery, 700 Children’s Drive, Columbus, OH
43205–2664, USA.
E-mail address: rajan.thakkar@nationwidechildrens.org (R.K. Thakkar).

https://doi.org/10.1016/j.burns.2023.01.010
0305-4179/© 2023 Elsevier Ltd and ISBI. All rights reserved.
1312 burns 49 (2023) 1311–1320

compared to 2nd degree superficial partial thickness burns (P < 0.01). CLDQI and SPRINT
scores demonstrated a similar pattern.
Conclusions: QoL is impacted in a substantial proportion of pediatric burn patients. Larger
TBSA and increased burn depths cause significantly more psychological stress in children,
and caregivers may require more extensive psychological evaluation.
© 2023 Elsevier Ltd and ISBI. All rights reserved.

Pediatric Burn Center from November 2019 - January 2021

1. Introduction were included in the study. Patients with incomplete demo­
graphic or burn characteristics data and 1st degree burns
When it comes to burn injury, children are recognized to were excluded. Study approval was given by the Institutional
carry a disproportionately high morbidity when compared to Review Board of Nationwide Children’s Hospital (Columbus,
outcomes in adult burn patients [1]. Many survivors not only OH), with the appropriate waiver of consent obtained. We
face physical disabilities and life-long scarring, but also evaluated the effect of patients’ skin conditions on their QoL
emotional and psychological disorders. Due to the high pre­ as well as the clinical burn characteristics (total body surface
valence of pediatric burns seen in clinical practice and their area (TBSA) burn, burn depth and degree, burn region (face/
debilitating outcomes, the acute and lasting psychosocial head/neck, thorax, extremities), single vs. multiple site
effects on children with burn injuries remains an important burns) most affecting QoL. We also evaluated the stress re­
area of interest for both the trauma community and primary sponse in parents or caregivers of children sustaining burns
care providers frequently treating these patients. and their need for further psychological evaluation. A sche­
Current American Burn Association (ABA) guidelines re­ matic diagram demonstrating patient selection and their
commend access to mental health support in the manage­ caregiver assessment completion rates is shown in Fig. 1.
ment of pediatric burn patients. However, in many hospitals
and burn centers there is no systematic process establishing
2.2. Psychological screening tools
routine psychological care by trained personnel or standar­
dized screening methods in place. Through the multi-dis­
2.2.1. Children’s Dermatology Life Quality Index
ciplinary approach of the Pediatric Injury and Quality
The Children’s Dermatology Life Quality Index © (Children’s
Improvement Collaborative (PIQIC), which is comprised of
Dermatology Life Quality Index. M S Lewis-Jones, A Y Finlay,
five pediatric trauma and burn centers advocating for ad­
May 1993; CDLQI) is a screening tool initially published in
vancement of quality burn care, the Psychology departments
1995 and was found to be practical, consistent, and valuable
promoted the necessity of a protocolized psychosocial mon­
in measuring QoL impairment in children 4–16 years old with
itoring in pediatric burn patients. This advocacy resulted in
dermatologic disease [7]. It was then validated for use in
all PIQIC institutions incorporating a standardized psycho­
measuring QoL impairments specifically in pediatric burn
social evaluation into the inpatient and outpatient care of all
patients by Parrish et al. in 2020 [4]. In our study, the CDLQI
children presenting with burn injuries [2].
was completed by pediatric burn patients ≥ 4–16 years old,
The breadth of literature related to quality of life (QoL)
with assistance of a caregiver if needed. The CDLQI is com­
disturbances seen in pediatric burn patients has improved
prised of 10 questions related to symptoms and difficulties
over the last decade, but varying outcomes have been re­
with mood, feelings, leisure, personal relationships, sleep,
ported and long-term effects are still unclear. Fewer studies
school or holidays, and treatments. Each question is scored
have explored associations which may be present between
on a Likert scale with a maximum of 3 points per question,
socioeconomic and clinical burn characteristics and the
making the minimum score 0 and the maximum score 30.
psychological burdens that children and their parents or
Higher scores indicate more QoL impairment. The meaning
caregivers experience after a burn injury [3–6]. The objective
of scores are the following: 0–1 = no effect on the child’s QoL,
of this study was to evaluate the effects of burn injuries on
2–6 = small effect, 7–12 = moderate effect, 13–18 = very large
pediatric burn patients’ and caregivers’ QoL and to identify
effect, and 19–30 = extremely large effect [7,8]. These cate­
the sociodemographic or clinical characteristics most asso­
gories were also utilized in our study.
ciated with psychological stress with the use of validated
screening tools.
3. Infant’s dermatology quality of life index

2. Methods Evaluating QoL in pediatric burn patients under 4 years old is

2.1. Study design
This study utilized a retrospective observational design.
Pediatric patients and their parents or caregivers who com­
pleted a psychological screening assessment during follow
up in burn clinic at an American Burn Association verified
often more difficult and there is lack of a validated measure
specifically for burn patients. However, the Infant’s
Dermatology Quality of Life Index © (M.S. Lewis-Jones, A.Y.
Finlay, Jan 2000; IDQOL) has been shown to be a good mea­
sure for clinical outcomes related to eczema with good test-
retest reliability, consistency, and interpretability in children
0–3 years and 11 months old [9]. Therefore, it has frequently
 burns 49 (2023) 1311–1320 1313

Fig. 1 – Schematic diagram of patient selection and their caregiver’s assessment completion (IDQOL - Infant’s Dermatology
QoL Index; CDLQI - Children’s Dermatology Life Quality Index; SPRINT - Short Post-Traumatic Stress Disorder Rating
Interview), IDQOL: Infant’s Dermatology Quality of Life Index; CDLQI: Children’s Dermatology Life Quality Index; SPRINT: Short Post-
Traumatic Stress Disorder Rating Interview.

been used to assess pediatric burn patients 0 to < 4 years of
age [4,5]. In our study, caregivers of pediatric burn patients 0
to < 4 years old completed the IDQOL. The IDQOL is com­
prised of 10 questions related to symptoms and difficulties
with mood, dressing, bathing, mealtimes, play, family activ­
ities, sleep, and treatments. Each question is scored on a
Likert scale with a maximum of 3 points per question,
making the minimum score 0 and the maximum score 30. A
higher score indicates more QoL impairment [9]. In our study,
IDQOL scoring was also categorized similarly to the CDLQI:
0–1 = no effect on the child’s QoL, 2–6 = small effect,
7–12 = moderate effect, 13–18 = very large effect, and
19–30 = extremely large effect.
4. Short post-traumatic stress disorder rating
interview
The Short Post-Traumatic Stress Disorder Rating Interview
(SPRINT) is a tool which was developed by Connor &
Davidson in 2001 for use in adults > 18 years old as a less
time-consuming, but structured post-traumatic stress dis­
order (PTSD)-specific measure [10,11]. In studies, it was
shown to have good test-retest reliability, consistency, and
convergent and divergent validity. Its questions evaluate so­
matic distress, stress vulnerability, and impairment in
function. Therefore, caregivers of pediatric burn patients who
were > 18 years old completed the SPRINT screening to
evaluate their stress response. The SPRINT screen is an 8
question self-assessment, which also uses the Likert scale,
with a maximum of 4 points for each question and a max­
imum total score of 32. SPRINT scores were assessed as
continuous, with a score > 14 indicating the need for further
structured psychological evaluation for PTSD, as suggested
by the validating authors [10].
4.1. Statistical analyses
Patients’ demographic and burn characteristics were sum­
marized and reported as medians and interquartile range
(IQR) for continuous variables and as frequencies and per­
centages for categorical variables (dichotomous or nominal).
Body region variables were grouped into four categories: 1)
head and neck; 2) chest, abdomen and back; 3) extremities;
and 4) multiple regions. The mean, standard deviation (SD),
minimum, and maximum scores for each variable within the
CDLQI and IDQOL were also reported. Patients’ overall QoL
assessment (IDQOL, CDLQI) scores were categorized as no
effect (score: 0–1); small effect (score: 2 – 6); moderate effect
(score: 7 – 12); very large effect (score: 13 – 18); and extremely
large effect (score: 19 – 30) for potential aggregation.
Caregiver assessments (SPRINT) scores were categorized as
1314 burns 49 (2023) 1311–1320
not needing further structured psychological evaluation for
PTSD (score: 0–14) and needing further structured pyscholo­
gical evaluation for PTSD (score: > 14).
Generalized linear mixed models (GLMM), with negative
binomial distribution, were fitted to separate models to
evaluate whether IDQOL, CDLQI and SPRINT scores were
associated with demographic and clinical burn character­
istics. Univariate analyses of individual variables were
completed to evaluate their association with IDQOL, CDLQI
and SPRINT scores separately using a chi-square test for
categorical variables and a Mann-Whitney U test for con­
tinuous variables, based on their distributions. All relevant
covariates with a P value < 0.2 were entered into the multi­
variable regression using GLMM. However, the number of
days elapsed between injury and assessment date was
considered in all three of the multivariable models irre­
spective of its significance level to account for potential
confounding effects of time elapsed from the date of injury.
Categorical factors which were identified to be associated
with QoL scores are presented with mean values (95% CI).
Model validation criteria and residual diagnostic plots were
used to test model fit. Analyses were performed using SAS
Enterprise guide 8.1 (SAS institute Inc., NC, USA). A subset
analysis was also performed using a similar set of models fit
for patients who were admitted to the hospital while ad­
justing for length of stay (LOS).
5. Results
Our cohort consisted of 272 burn patients; however, 28 pa­
tients were excluded based on exclusion criteria. A total of
244 patients were included, with a 143/143 (100%) assessment
completion rate for the IDQOL (0 to < 4 years old), a 96/101
(95.1%) response rate for the CDLQI (≥4–16 years old), and a
65.2% (159/244) response rate for the SPRINT completed by
caregivers (> 18 years old) of all patients (Fig. 1).
The mean age of pediatric burn patients in our cohort
was 5.3 years (SD: + 4.8), and a majority of patients were
male (56.1%), non-Hispanic (97.5%), and White (67.2%).
Payment was most often through Medicaid insurance
(51.6%). Most patients sustained a single site burn (78.3%), a
burn to the extremities (hand, arm, foot, leg – 67.6%), and a
2nd degree superficial partial thickness (65.9%) burn depth.
Scald burns were most common (44.3%). The mean total
body surface area (TBSA) burn at initial presentation was
2.7% (SD: + 4.8) but ranged from 0.5% to 41%. The mean
number of days from injury to survey completion was 9.1
days (SD: + 7.0). Patients responding to the CDLQI were a
mean age of 10.4 years old (SD: + 3.4), while children whose
caregivers responded to the IDQOL were a mean age of 1.9
years old (SD: + 1.3). Most children whose caregivers com­
pleted the IDQOL were male (62.9%), while most children
completing the CDLQI were female (55.2%; p < 0.01). For
IDQOL, CDLQI, and SPRINT assessments, a majority of pa­
tients sustained scald burns and burns to the extremities
(p < 0.01). Most patients responding to CDLQI were ad­
mitted to the hospital for their burn (84.5%), whereas pa­
tients with an IDQOL completed mostly underwent no
hospital admission (78.3%; p < 0.01) (Table 1).
Overall, 27.3% of caregivers completed IDQOL assessments
which indicated that their child’s skin condition caused a
moderate to extremely large effect on their QoL. A higher
proportion of children who completed the CDLQI assessment
(53.1%) indicated that their skin condition caused a moderate
to extremely large effect on their QoL. When evaluating care­
givers’ psychological burden, 4.5% completed a SPRINT as­
sessment with a score > 14, which warranted the need for
further structured psychological evaluation for PTSD due to
their child’s burn (Fig. 2). The mean QOL score was also found
to be higher in CDLQI assessments compared to IDQOL as­
sessments by 2.9 (95% CI 1.6–4.0) (p < 0.01) (Table1). Associa­
tions between individual covariates and their corresponding
QoL scores (IDQOL, CDLQI, SPRINT) are presented in Table 2.
When evaluating responses to the CDLQI, the variable
with the highest score was, “Over the last week, how much
have you avoided swimming or other sports because of your
skin trouble?” (1.49, SD: + 1.32, minimum: 0, maximum: 3).
This was followed by, “Over the last week, how itchy,
“scratchy,” sore, or painful has your skin been?” (1.45, SD: +
0.98, minimum: 0, maximum: 3). The variable with the lowest
score was, “Over the last week, how much has your skin af­
fected your friendships?” (0.10, SD: + 0.36, minimum: 0,
maximum: 2). When evaluating parent/caregiver responses
to the IDQOL, the variables with the highest scores were,
“Over the last week, how much has your child having skin
issues been a problem at bath-time?” (0.81, SD: + 1.08,
minimum: 0, maximum: 3) and “Over the last week, has your
child’s skin issues meant that dressing and undressing the
child has been uncomfortable?” (0.70, SD: + 0.89, minimum: 0,
maximum: 3). The variable with the lowest score was “Over
the last week, have there been problems with your child
caused by the treatment?” (0.19, SD: + 0.46, minimum: 0,
maximum: 2). For each of these particular variables: 0 = not
at all, 1 = only a little, 2 = quite a lot, and 3 = very much.
Notably, some IDQOL response choices vary based on the
variable (Supplementary Table 1).
When adjusting for the time elapsed between injury date
and survey completion date, the multivariable regression
model suggests that on average, each additional 1% of TBSA
burn is associated with an increase of 2.75 points on the
IDQOL assessment (p = 0.05). Similarly, each 1-day elapsed
from the date of injury is associated with a decrease of 3.53
points on the IDQOL assessment (p = 0.01). QoL scores would
also be higher by 3.3 points for patients sustaining 2nd degree
deep partial thickness burns (2D) compared to those sus­
taining a 2nd degree superficial partial thickness burn (2 S)
burn (P < 0.01); however, this was not demonstrated in those
who sustained 3rd degree burns (Fig. 3). The mean and 95% CI
score estimate for each category per variable is shown in
Table 3.
On the CDLQI, each additional 1% of TBSA burn is sig­
nificantly associated with an increase of 2.05 points (P = 0.04).
Though days elapsed from injury date to survey date was not
significantly associated with the CDLQI score (P = 0.12), an
increase in elapsed days still tended to decrease the CDLQI
score (Table 4). The SPRINT assessment had a suggested as­
sociation with TBSA burn, with each additional 1% being as­
sociated with an increase of 3.38 points (P = 0.05). SPRINT
scores are also suggestively higher by 2.48 points for patients
 burns 49 (2023) 1311–1320 1315

Table 1 – Patient demographics and burn characteristics.

Total P-value IDQOL CDLQI SPRINT
(n = 244) (n = 143) (n = 96) (n = 159)
QOL score (mean, SD) 4.9 (+4.5) 7.8 (+4.9) 3.9 (+4.7)
Age (mean, SD) 5.3 (+4.8) 1.9 (+1.3) 10.4 (+3.4) 5.6 (+4.8)
Days from injury date to survey date 9.1 (7.00) 9.4 (8.9) 8.6 (10.5) 8.9 (9.5)
TBSA burn at initial presentation (%) 2.7 (4.8) 3.9 (5.7) 2.2 (3.2) 2.7 (4.7)
TBSA burn at survey (%) 1.5 (2.1) 1.4 (1.8) 1.7 (2.6) 1.6 (2.4)
Gender Female 107 (43.9%) 0.05 53 (37.1%) 53 (55.2%) 74 (46.5%)
Male 134 (56.1%) 90 (62.9%) 47 (46.5%) 85 (53.5%)
Race Asian 4 (1.6%) < 0.01 4 (2.8%) 0.00 4 (2.5%)
Black 63 (25.8%) 40 (27.9%) 21 (21.9%) 41 (25.8%)
Multi-racial 13 (5.3%) 4 (2.8%) 9 (8.4%) 11 (6.9%)
White 164 (67.2%) 95 (66.4%) 66 (68.8%) 103 (64.8%)
Ethnicity Hispanic or Latino 6 (2.5%) < 0.01 4 (2.8%) 2(2.1%) 4 (2.5%)
Not Hispanic or Latino 238 (97.5%) 139 (97.2%) 94 (97.9%) 155 (97.5%)
Payor Source Medicaid/CHIP 126 (51.6%) < 0.01 75 (52.5%) 49 (51.0%) 83 (52.2%)
Multiple 14 (5.7%) 8 (5.6%) 5 (5.2%) 9 (5.7%)
Private/Commercial 94 (38.5%) 53 (37.1%) 39 (40.6%) 59 (37.1%)
Self-pay 10 (4.1%) 7 (4.9%) 3(3.1%) 8 (5.0%)
Burn Region Head and neck only 10 (4.1%) < 0.01 7 (4.9%) 3 (3.1%) 9 (5.7%)
Chest, abdomen and 16 (6.6%) 13 (9.1%) 3 (3.1%) 11 (6.9%)
back only
Extremities (hand, arm, 165 (67.6%) 90 (62.9%) 71 (73.9%) 103 (64.8%)
leg, foot) only
Multiple regions 53 (21.7%) 33 (23.1%) 19 (19.8%) 36 (22.6%)
Number of burn regions Single 191 (78.3%) < 0.01 110 (76.9%) 77 (80.2%) 123 (77.4%)
sustained Multiple 53 (21.7%) 33 (23.1%) 19 (19.8%) 36 (22.6%)
Mechanism of burn Contact 86 (35.3%) < 0.01 54 (37.7%) 29 (30.2%) 47 (29.6%)
Flame 28 (11.5%) 6 (4.2%) 21 (21.9%) 23 (14.5%)
Friction 18 (7.4%) 12 (8.4%) 6 (6.3%) 12 (7.6%)
Scald 108 (44.3%) 68 (47.6%) 39 (40.6%) 74 (46.5%)
Other (chemical, 4 (1.6%) 3 (2.1%) 1 (1.4%) 3 (1.9%)
electrical)
Depth of burn sustained 2nd degree superficial 161 (65.9%) < 0.01 97 (67.8%) 59 (61.5%) 113 (71.1%)
2nd degree deep 61 (25.0%) 35 (24.5%) 26 (27.1%) 33 (20.8%)
3rd degree 22 (9.1%) 11 (7.7%) 11 (11.5%) 13 (8.2%)
Admission status PCP/ED/UC/ 197 (80.7%) < 0.01 112 (78.3%) 14 (14.6%) 132 (83.0%)
clinic referral not
admitted
Inpatient admission 47 (19.3%) 31 (21.7%) 82 (85.4%) 27 (16.9%)
IDQOL: Infant’s Dermatology Quality of Life Index; CDLQI: Children’s Dermatology Life Quality Index; SPRINT: Short Post-Traumatic Stress
Disorder Rating Interview.

Within our cohort, 19.3% of patients were admitted to the

Fig. 2 – Quality of life assessment scores by effect categories
(for IDQOL, CDLQI: 0 −1: no effect; 2 - 6: small effect; 7 - 12:
moderate effect;13 – 18: very large effect; 19 - 30: extremely
large effect, IDQOL: Infant’s Dermatology Quality of Life Index;
CDLQI: Children’s Dermatology Life Quality Index.
sustaining 3rd degree burns (3) compared to those sustaining
a 2nd degree superficial partial thickness burn (2 S) burn
(P = 0.05) (Table 5) (Fig. 3).
hospital. When performing a subset analysis which adjusted
for LOS within this population, LOS was not associated with
IDQOL, CDLQI, or SPRINT scores. When including LOS in the
models, trends remained similar between IDQOL, CDLQI, and
SPRINT scores and 1) TBSA burn at initial presentation and 2)
days from injury to survey. The larger the TBSA burn and the
less days between injury and survey, the higher the QoL
scores were). However, they were not statistically significant
(Supplementary Tables 2–4).
6. Discussion
Burn injuries are traumatic, life-changing events for children,
and studies have demonstrated that traumatic injuries in
childhood can affect physical and behavioral development
while also causing long-term psychological impacts [12–14].
Our study evaluated the effect on QoL in children 0–16 years
1316 burns 49 (2023) 1311–1320

Table 2 – Univariate analyses of patient demographics and burn characteristics.

IDQOL p-value CDLQI p-value SPRINT p-value
(n = 143) (n = 96) (n = 159)
Age (median, IQR) 0.68 0.64 0.81
Days from injury date to survey date (days) 0.90 0.97 0.51
TBSA burn at initial presentation (%) 0.05 0.11 0.05
TBSA burn at survey (%) 0.04 0.97 0.51
Gender Female 0.31 0.93 0.76
Male
Race White 0.62 0.27 0.88
Black
Asian
Multi-racial
Ethnicity Non-Hispanic or Latinx 0.71 0.53 0.89
Hispanic or Latinx
Payor Source Medicaid/CHIP 0.39 0.99 0.51
Private/Commercial
Self-pay
Multiple
Burn Region Head and neck only 0.24 0.34 0.21
Chest, abdomen and back only
Extremities (hand, arm, leg,
foot) only
Multiple
Number of burn regions Single 0.05 0.53 0.29
sustained Multiple
Mechanism of burn Scald 0.18 0.45 0.25
Contact
Flame
Friction
Other (chemical, electrical)
Depth of burn sustained 2nd degree superficial 0.02 0.45 0.13
2nd degree deep
3rd degree
Admission status PCP/ED/UC/clinic referral not 0.34 0.16 0.11
admitted to the hospital
Inpatient admission
IDQOL: Infant’s Dermatology Quality of Life Index; CDLQI: Children’s Dermatology Life Quality Index; SPRINT: Short Post-Traumatic Stress
Disorder Rating Interview

old, as well as the need for further PTSD assessment in their
caregivers. According to caregiver responses, just over one-
quarter of children 0 to < 4 years old and over half of children
≥ 4–16 years old experienced a moderate to extremely large
effect on their QoL due to their skin condition after sustaining
a burn injury. Though a smaller number of caregivers met the
threshold for needing further structured psychological eva­
luation for PTSD after their child sustained a burn injury
(4.5%, SPRINT score > 14), the number is not clinically insig­
nificant, and the mental health of caregivers is important to
address when treating pediatric burn patients.
Numerous studies have examined psychological burdens
and QoL in children with burns, but few have investigated
the clinical characteristics most associated with these out­
comes [6]. Conflicting findings have also been reported. A
study done by Stoddard et al. (1989), compared psychiatric
outcomes between pediatric burn patients and a nonburn
patient sample and found that the children sustaining burns
had higher levels of anxious disorders, phobias, depressive
symptoms, and PTSD [15]. Maskell et al. studied QoL, psy­
chological adjustment, and self-concept in pediatric burn
patients 8–17 years old with burn scarring and found that,
compared to healthy peers, they demonstrated significantly
lower QoL and increased behavioral difficulties, though no
differences in self-concept were noted [3]. More recently,
Stewart et al. (2019) also used the caregiver completed
IDQOL, but to describe the effect of pruritis on pediatric burn
patients with smaller burns (mean TBSA burn = 4%). Forty-
seven percent of their cohort of children 0–4 years old were
affected by pruritis following burn injury, with child min­
ority race, increased TBSA burn, and more days elapsed
since burn injury predicting more severe pruritis. They also
found positive correlations between pruritis and irritability
and sleep disturbances [5]. Our study demonstrated similar
results, with one-third to over half of our patients experi­
encing moderate to extremely large effects on QoL after
their burn. Older children were also more affected by the
size of their burn, and younger children were more affected
by both burn size and burn depth. Although not assessed in
our study, Oh et al. (2017) found that scar characteristics
were more likely to determine QoL after a burn injury than
burn severity, which suggests that longer-term follow up of
these patients’ scarring and contracture development is
important [16].
 burns 49 (2023) 1311–1320 1317

Fig. 3 – Relationship between total body surface area burn and highest degree burn sustained and quality of life scores (data
points generated from multivariable regressions), 2 S = 2nd degree superficial partial thickness; 2D = 2nd degree deep partial
thickness; 3 = 3rd degree, IDQOL: Infant’s Dermatology Quality of Life Index; CDLQI: Children’s Dermatology Life Quality Index.

Contrastingly, studies done by Pope et al. (2007) and refuted these results, authors cautiously suggested that burn
Lawrence et al. (2007) showed that adolescent burn survivors patients may cope better than previously thought, despite
reported higher body image satisfaction and QoL compared the physical and psychosocial consequences of burn injuries
to age-matched control groups. Though previous findings [3,17,18]. Of note, these two studies focused only on

Table 3 – Multivariate model for Infant’s Dermatology Quality of Life Index.

Variable Level Estimate SE P-value Mean IDQOL score (95% CI)
TBSA burn at initial presentation 2.75 1.40 0.05
Days from injury date to survey date -3.53 1.34 0.01
Burn Region Single Ref 4.8 (3.5, 6.7)
Multiple -0.01 1.01 0.99 4.9 (2.9,8.1)
Mechanism of burn Scald Ref 6.4 (4.6–8.9)
Contact -1.91 1.07 0.08 4.6 (3.2, 6.6)
Flame 0.29 0.90 0.75 7.2 (3.5–14.8)
Friction -1.48 1.11 0.19 4.1 (2.2–7.3)
Other -1.24 1.02 0.22 3.1 (0.9–9.9)
Burn Depth 2S Ref 3.3 (2.3,4.9)
2D 3.33 0.95 < 0.01 6.4 (4.2,9.7)
3 1.48 1.06 0.16 5.3 (2.8,10.0)
IDQOL: Infant’s Dermatology Quality of Life Index.
1318 burns 49 (2023) 1311–1320

Table 4 – Multivariate model for Children’s Dermatology Life Quality Index.

Variable Level Estimate SE P-value Mean CDLQI score (95% CI)
Total TBSA at initial presentation 2.05 0.96 0.04
Days from injury date to survey date -1.48 0.94 0.12
Burn Region Single 8.2 (6.9,9.7)
Multiple -1.00 0.77 0.20 5.8 (3.4, 9.9)
Burn depth 2S 6.1 (4.7,7.9)
2D 0.29 0.70 0.62 6.6 (4.5,9.5)
3 0.89 0.71 0.21 8.1 (5.0–13.2)
CDLQI: Children’s Dermatology Life Quality Index

Table 5 – Multivariate model for Short Post-Traumatic Stress Disorder Rating Interview.
Variable Level Estimate SE P-value Mean SPRINT score (95% CI)
Total TBSA at initial presentation 3.38 1.71 0.05
Days from injury date to survey date -2.10 1.43 0.15
Burn depth 2S 3.4 (2.7,4.2)
2D 0.84 1.20 0.49 4.0 (2.6,6.1
3 2.48 1.27 0.05 6.9 (3.6, 13.7)
SPRINT: Short Post-Traumatic Stress Disorder Rating Interview

adolescent populations, which highlights the consideration
that different age groups may be burdened by psychosocial
disturbances in different ways and/or have varying age-re­
lated capabilities to cope with these burdens. Le Doux et al.
found that children sustaining burns reported significantly
higher self-esteem and self-concept than the control sample.
They also noted that burned children placed less importance
on areas which were out of their control and were satisfied
with themselves in areas they held most important. In this
case, authors suggested that positive reports of self-esteem in
pediatric burn patients could be an attempted defense me­
chanism [14].
A surprising finding in our study was that burns to the
head and neck were not found to significantly affect our
younger or older patients’ QoL as compared to burns located
on the torso and extremities. Just 16.4% of our cohort sus­
tained burns to the head/neck, but this region is typically at
an overall increased risk for burn injury due to its rarely being
protected by clothing. The face is also a focal point in one’s
personal identity and is readily exposed to the public. It
controls vital functions like eating, vision, and speech, but
also allows us to participate in social interactions [19]. It may,
therefore, require advanced treatment to obtain both func­
tional and aesthetically pleasing outcomes for the patient
[20]. Burns to the face/head may also lead to societal stigma,
amplifying psychosocial issues during recovery; however,
QoL was not influenced as we had expected during the
follow-up of this cohort [19,21].
More studies exist which examine the psychological
burden on caregivers following a burn injury in a child.
Though a smaller proportion of caregivers in our cohort met
SPRINT criteria for structured PTSD evaluation (4.5%), studies
have consistently demonstrated that a burn injury to a child
may be one of the most stressful life events for a parent/
caregiver [22–27]. Evidence has also shown that caregivers
tend to experience guilt, depression, anxiety, hostility, and
post-traumatic stress responses after their child’s burn
injury. Furthermore, parent coping has been shown to di­
rectly affect adjustment capabilities in children [22,23,27,28].
Fukunishi studied 16 pairs of mothers and children with
scald injuries and found that 6.3% and 0% of children ex­
perienced PTSD and major depression, respectively. How­
ever, their mothers were more psychologically affected, with
12.5% experiencing PTSD and 18.5% experiencing major de­
pression [29]. Using elements from the SPRINT, Seivert et al.
(2019) demonstrated that parents of non-White children were
found to report higher depression scores [30,31]. Rizzone
et al. (1994) determined that 52% of mother’s whose child
experienced a large burn (mean TBSA burn = 37.9%) met
criteria for PTSD at one point after their child’s burn injury.
This result could help explain our small proportion of care­
givers who met PTSD criteria, as the median TBSA burn in our
cohort was 1.0%. Multiple other studies also support our
findings that suggest an increase in TBSA burn is associated
with increased PTSD symptoms in caregivers [23,27,32].
These results and the consistent evidence within the litera­
ture suggest that routine caregiver distress screening is ne­
cessary after a pediatric burn injury.
7. Limitations
There are a few limitations associated with this study. First,
this was a retrospective cohort design which focused only on
pediatric burn patients without a corresponding control
group for comparison, as seen is a few other studies within
the literature [3,14,15,17,18]. However, the IDQOL and CDLQI
are consistent and valuable QoL tools which are skin-focused
and have been validated for use specifically in burn patients.
Another limitation of this study is the time interval from date
of injury to survey completion (median 9 days). Although this
may be an early timeframe to conduct QOL assessments in
burn patients, it does provide some insight as to how they are
affected after leaving the hospital. Difficulties with sleep,
 burns 49 (2023) 1311–1320
pain, pruritus, mood, feelings, leisure, personal relationships,
school or holidays are among some of the aspects we were
able to evaluate, even in a short follow up time period. Fur­
ther studies conducting QOL assessments at 3 months, 6
months, and 1 year would be beneficial to evaluate longer-
term outcomes, such as scarring and contracture. We were
also limited by the variables available within our dataset,
specifically, in our ability to assess the types of dressings,
dermal substrates, and grafts utilized in each patient and
their need for surgical procedures. These are important
variables which affect patients’ clinical progress and should
be studied in the future.
Additionally, while hospital admission LOS may be a po­
tential confounder influencing QoL scores, in our cohort, less
than 20% of patients had a hospital admission with a
LOS > 1 day. To explore potential confounding, a sensitivity
analysis was performed in this subset of patients to include
LOS in the multivariate models. Results showed that LOS was
positively associated with the QoL scores, but it was not
statistically significant. However, it is possible that our study
was not powered to detect an association between QoL and
LOS due to the low number of patients with LOS > 1 day.
Larger, multi-institution studies would likely be beneficial in
further identifying more rare clinical characteristics and their
effect on QoL in children with burns.
Our study is unique in that is evaluates multiple age
groups’ QoL using skin-focused validated assessments
(IDQOL and CDLQI). It concurrently evaluates the psycholo­
gical disturbances in caregivers using the SPRINT assess­
ment, which is an updated and validated tool used to screen
for PTSD. We were also able to identify clinical burn char­
acteristics, like TBSA burn and burn depth, which may in­
crease a child’s likelihood to experience QoL disturbances
and a caregiver’s likelihood to need a structured psycholo­
gical assessment for PTSD. These findings may be helpful
during follow up for patients, in that younger children with
larger or 2nd degree deep partial thickness burns, older
children with larger burns, and caregivers of patients with
larger or 3rd degree burns may need closer psychological
follow up. We also found that burns to the face, head, and
neck did not significantly affect our children’s QoL as com­
pared to burns sustained to other areas of the body, and this
was surprising to us as adult providers because we expected
face/head/neck burns to be the cause of more distress. This
could be attributed to more superficial and often single site
burns being sustained to the head/neck compared to other
body regions or may be attributed to a smaller number of
patients with head/neck burns.
8. Conclusion
QoL is often complex and individualized to the experiences of
the patient or their caregiver; however, it is fair to say that for
many of our pediatric burn patients and their families, QoL
will be impacted in some way. Pediatric patients and their
caregivers would, therefore, benefit from universal psycho­
logical screening and/or intervention after burn injury.
Future studies which assess QoL in these patients long­
itudinally (i.e. 1 month, 6 months, and 1 year) could provide
1319
insight as to whether effects on QoL from burn injury in­
crease or decrease over time. This may help providers who
perform follow up care for these patients understand whe­
ther effects on QoL are more related to the initial TBSA burn
and/or severity or to the subsequent scarring that patients
develop.
Funding
None.
CRediT authorship contribution statement
Kelli Patterson, Katherine Lehman, and Sarah VerLee con­
ceptualized and designed the study, coordinated data col­
lection, drafted the initial manuscript, and reviewed and
revised the manuscript, Tariku Beyene designed the data
collection instruments, collected data, carried out the initial
analyses, and reviewed and revised the manuscript, Dana
Schwartz, Renata Fabia, and Rajan Thakkar conceptualized
and designed the study, coordinated and supervised data
collection, and critically reviewed the manuscript for im­
portant intellectual content, All authors approved the final
manuscript as submitted and agree to be accountable for all
aspects of the work.
Conflicts of interest statement
All authors have no conflicts of interest to declare. The au­
thors have no commercial associations or sources of support
that might pose a conflict of interest.
Appendix A. Supporting information
Supplementary data associated with this article can be found
in the online version at doi:10.1016/j.burns.2023.01.010.
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