Laura Rosenberg

Imipramine treatment in Pediatric burn patients with symptoms of acute stress disorder : A pilot study

OBJECTIVEnPediatric burn patients often exhibit acute stress disorder (ASD) symptoms. Information on psychopharmacological treatment of ASD symptoms in children is scarce. This pilot study used a prospective, randomized, double-blind design to test whether thermally injured children suffering ASD symptoms benefit from imipramine.nnnMETHODnTwenty-five children, aged 2 to 19 years, received either imipramine or chloral hydrate for 7 days. A structured interview (clinically useful, but validity and reliability not yet established) was used to assess the presence and frequency of ASD symptoms both before treatment and 3 times during the treatment period.nnnRESULTSnEleven females and 14 males participated, with a mean total burn surface area of 45% (SD = 23%) and mean age of 8 years (SD = 6). Imipramine was more effective than chloral hydrate in treating ASD symptoms (chi 2 [1, N = 25] = 5.24, p < .02). Five of 13 were positive responders to chloral hydrate (38%). Ten of 12 were positive responders to low-dose imipramine (83%).nnnCONCLUSIONSnThis pilot study suggests a place for cautious initial use of imipramine to reduce ASD symptoms in burned children. Care must be taken to minimize cardiovascular risks in an off-label application of imipramine in children, especially those receiving additional medications.

Disfiguring burn scars and adolescent self-esteem.

Although children with burn scars are reported to have positive self-concepts, social and sexual maturation can be expected to stimulate anxiety, depression and diminished self-esteem in adolescents with disfiguring scars. This study examines complex self-regard of adolescents with burn scars. The following were hypothesized: (1) adolescents with disfiguring burn scars would view themselves as less competent than unburned normative samples; (2) subjects perceived competence would be incongruent with the importance ascribed to the domains of physical appearance and athletic competence and (3) depression/anxiety would correlate negatively with perceived competence. Subjects were 14 adolescents: 6 male and 8 female, 13-20 years old, at least 2 years post-burn injury (TBSA = 39% +/- 23%). All had scars in at least 2 of the following areas: head/face, neck, chest, hands, genitals. Each subject was administered the Harter Self Perception Profile, a standardized measure of self-competence and value in 8 domains plus a general competence measure. The subjects were also assessed for anxiety/depression by the Child Behavioral Checklist. Overall, adolescents in this sample exhibited a similar or higher degree of self-worth as compared to their peers. However, the athletic competence and physical appearance sub-domains of self-worth for the burn survivors were significantly lower as compared to the normative group. Half of the participants rated the importance of physical appearance to be higher than their level of personal competence in this area, making for distressing emotions. Mood was similar to the normative group and mood correlated significantly with self-worth.

Psychosocial care of persons with severe burns

Treatment of people with burn injuries includes recovery of optimal function for survivors to fully participate in society, psychologically and physically. Increased likelihood of physical survival has led to greater concern for potential psychological morbidity for the burn survivor. Based on research and on many years of clinical experience in providing psychosocial care to burned children and adults, the authors outline their approach to assisting burn survivors and their families through the arduous process of recovery from admission through critical care, inpatient recuperation and reintegration upon hospital discharge. A philosophy of rehabilitation, a process that may occur for many months or years after patients discharge from their acute hospitalization, is presented in the form of seven guidelines for working with burn survivors.

Propranolol does not reduce risk for acute stress disorder in pediatric burn trauma

OBJECTIVEnAcute stress disorder (ASD) can interfere with satisfactory recovery of children with severe burn injuries. Recent studies have found propranolol to be effective in reducing posttraumatic symptoms, but the benefits of this medication with ASD are unknown. Therefore, we hypothesized that individuals who were administered propranolol acutely would be less likely to develop ASD than those who were not.nnnMETHODnA review of electronic medical records was conducted on the children included in a previous blinded randomized-control trial, in which the participants received propranolol or no propranolol during the acute phase of recovery (first 30 days). These data were merged with electronic information regarding medication treatment for ASD. The psychologists and clinicians who had previously assessed for ASD for purposes of treating the childrens distress were blinded to who received propranolol and who did not.nnnRESULTSnThere were 363 participants (232 boys, 131 girls) and the mean total body surface area was 56%. Of this sample, 22 participants had been previously diagnosed and treated for ASD, and 341 were in a non-ASD group. Eight percent of those children who received propranolol required treatment for ASD, whereas 5% of children who received no propranolol also required treatment for ASD. No statistically significant difference was noted.nnnCONCLUSIONSnPropranolol was not found to influence the risk for subsequent ASD. This finding is in contrast to the observed benefit of propranolol reported in other studies with different at risk populations. Further exploration is warranted to assess the possible long-term benefit on posttraumatic symptoms in pediatric burn survivor patients.

Treating thermally injured children suffering symptoms of acute stress with imipramine and fluoxetine: A randomized, double-blind study

INTRODUCTIONnFor pediatric burn patients with the symptoms of acute stress disorder (ASD) a first line medication is not widely agreed upon. A prospective, randomized, placebo controlled, double-blind design was used to test the efficacy of imipramine and fluoxetine.nnnMETHODnPatients 4-18 years of age with symptoms of ASD were randomized to 1 of 3 groups: imipramine, fluoxetine, or placebo for 1 week. Daily imipramine dose was 1mg/kg, with the maximum dose being 100mg. Daily fluoxetine dose was 5mg for children weighing >or=40 kg; 10mg for those weighing between 40 and 60 kg; 20mg for those weighing >60 kg.nnnRESULTSnSixty participants, 16 females and 44 males, had an average body surface area burn of 53% (S.D.=18) and average age of 11 years (S.D.=4). Imipramine subjects received an average daily dose of 1.00+/-0.29 mg/kg. Fluoxetine subjects received an average daily dose of 0.29+/-0.16 mg/kg. Between group differences were not detected. Fifty-five percent responded positively to placebo; 60% responded positively to imipramine; and 72% responded positively to fluoxetine.nnnCONCLUSIONnWithin the parameters of this study design and sample, placebo was statistically as effective as either drug in treating symptoms of ASD.

A Double-Blind Study of the Analgesic Efficacy of Oral Transmucosal Fentanyl Citrate and Oral Morphine in Pediatric Patients Undergoing Burn Dressing Change and Tubbing

Burn wound care is extremely painful. The pain leads to added anxiety and therefore a distressing treatment that can negatively impact healing. Pain and anxiety management with oral transmucosal fentanyl citrate was compared with this institutions standard procedural pain medication, morphine. With a double-blinded, reverse crossover, time-randomized, and placebo-controlled design, the efficacy of morphine and fentanyl citrate was assessed with patients undergoing two consecutive days of tubbing. Pain and anxiety was assessed before, during, and after the tubbing procedure using the Faces Pain Rating Scale (Whaley and Wong, 1987) and the Fear Thermometer (Silverman and Kurtines, 1996). Data were analyzed with repeated measures analysis of variance. Pain and anxiety appeared better managed with fentanyl citrate. Generalization is limited by small sample size, yet findings warrant additional investigation.

Perceived stigmatization and social comfort: validating the constructs and their measurement among pediatric burn survivors.

OBJECTIVEnThe current study implemented a four-step process to evaluate the measurement properties of the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) among long-term pediatric burn survivors.nnnMETHODSnFirst, a series of confirmatory factor analyses (CFAs) compared the hypothesized four-factor model--3 perceived stigmatization factors (absence of friendly behavior, confused and staring behavior, and hostile behavior)--and one social comfort factor to three other models. Second, we tested the measurement invariance of the instruments between pediatric and adult burn survivor samples. Third, possible differences in structural parameters across groups were tested. Fourth, we tested whether the three perceived stigmatization factors and the social comfort factor loaded on one second-order factor. Participants included 369 pediatric and 347 adult burn survivors.nnnRESULTSnThe four-factor model was superior to the comparison models. The PSQ and SCQ demonstrated measurement invariance. Factor variance, factor covariance, and the latent means of the PSQ did not vary across groups. The adult group had a significantly lower latent mean on the SCQ than the pediatric group. The three factors of the PSQ and the one-factor SCQ loaded on one second-order factor.nnnCONCLUSIONnThe results of this study lend support to both the construct validity of perceived stigmatization and social comfort and the potential value of the PSQ and SCQ for studying the social experience of people with visible differences.

Early treatment of acute stress disorder in children with major burn injury

Objective: This study examines retrospectively the response rate of pediatric burn survivors with acute stress disorder to either imipramine or fluoxetine. Methods: On retrospective chart review, 128 intensive care unit patients (85 boys, 43 girls) with 52% ± 20% total body surface area burn, length of stay of 32.8 ± 25.2 days, mean age of 9.1 ± 4.7 yrs, and age range of 13 months to 19 yrs met criteria for acute stress disorder after ≥2 days of symptoms and were treated with either imipramine or fluoxetine. If significant improvement did not occur within 7 days, the medication was either increased or switched to the other class. Results: Initially, 104 patients were treated with imipramine and 24 with fluoxetine. A total of 84 patients responded to imipramine: seven of these patients required a higher dose. A total of 18 patients responded to initial fluoxetine treatment. Of 26 nonresponders to the initial medication, 13 imipramine failures and one fluoxetine failure refused further treatment. The other 12 responded to the second medication. Therefore, 114 of 128 treated patients (89%) responded to either fluoxetine (mean dose, 0.30 ± 0.14 mg/kg) or imipramine (mean dose, 1.30 ± 0.55 mg/kg). Response was independent of sex and age but was less for those with burns of >60% total body surface area. The side effects of each medication were not significant. Most patients continued treatment for ≥3 months; some required 6 months of treatment before successful discontinuation. Conclusions: Early treatment of acute stress disorder with either imipramine or fluoxetine is often able to reduce its symptoms. This is a review of a single hospital’s experience in managing psychiatric distress in this very high-risk group of burned children. Additional clinical studies are needed before generalizing these findings.

Phantom limb pain in pediatric burn survivors

Phantom limb sensation and pain are reported by youth following amputations. While youth survivors of severe burns may require amputation as a part of their treatment, the authors are unaware of any descriptions as to the rates and features of phantom limb sensation and pain in this population. A retrospective chart review of all youth that were admitted to a burn care unit over the past 30 years and received amputations as part of their treatment was conducted to describe the rate of phantom sensation and pain. In the 34 patients with major limb amputations, phantom limb pain occurred at a rate similar to that reported in other studies and was an important issue in their care. Patients with amputations following electrical burn injury had a significantly higher rate of phantom limb pain than those with amputations following flame burn injury.

Itch assessment scale for the pediatric burn survivor

The objective of the study is to evaluate the validity and reliability of the Itch Man Scale developed in 2000 by Blakeney and Marvin in assessing the intensity of itch in the pediatric burn patient. Forty-five patients (31 males and 14 females; average age 9.9 ± 5.0 years; and % TBSA burned 41 ± 25%) with an established itch complaint were studied. They were asked to describe the severity of their itch by two independent raters to determine test-retest reliability. Individuals aged 6 years or older were assessed using parental informants. Concurrent validity was determined by comparing three scales to quantify the level of itch: the Itch Man Scale (a 5-point Likert scale), the 5-D Itch Scale (adapted from a scale for peripheral neuropathy), and the Visual Analog Scale for itch. Itch Man Scale ratings collected from independent raters showed a strong correlation (r = .912, P < .0001). The Itch Man Scale also correlated significantly with the Visual Analog Scale, the gold standard for measurement of pruritus (r = .798, P < .0001). The total summated score of the Duration, Degree, Direction, and Disability domains from the 5-D Itch Scale had a significant correlation with the Itch Man Scale (r = .614, P < .0001). The Degree domain is the only individual component with a significant correlation (r = .757, P < .0001). The Itch Man Scale is a reliable and valid tool to assess itching in pediatric burn patients and to quantify postburn pruritus.