Background: Patient survival after severe burn injury is largely determined by burn size. Modern developments in burn care have greatly improved survival and outcomes. However, no large analysis of outcomes in paediatric burn patients with present treatment regimens exists. This study was designed to identify the burn size associated with significant increases in morbidity and mortality in paediatric patients. Methods: We undertook a single-centre prospective observational cohort study using clinical data for paediatric patients with burns of at least 30 of their total body surface area (TBSA). Patients were stratified by burn size in 10 increments, ranging from 30 to 100 TBSA, with a secondary assignment made according to the outcome of a receiver operating characteristic (ROC) analysis. Statistical analysis was done with Student's t test, χ2 test, logistic regression, and ROC analysis, as appropriate, with significance set at p<0·05. Findings: 952 severely burned paediatric patients were admitted to the centre between 1998 and 2008. All groups were comparable in age (mean 7·3 [SD 5·3] years, ranging from 6·1 [5·1] years in the 30-39 TBSA group to 9·6 [5·4] years in the 90-100 TBSA group) and sex distribution (628  boys, ranging from 59 [73/123] in the 60-69 TBSA group to 82 [42/51] in the 90-100 TBSA group). 123 (13) patients died (increasing from 3 [five of 180] in the 30-39 TBSA group to 55 [28/51] in the 90-100 TBSA group; p<0·0001), 154 (16) developed multiorgan failure (increasing from 6 [ten] in the 30-39 TBSA group to 45  in the 90-100 TBSA group; p<0·0001), and 89 (9) had sepsis (increasing from 2 [three] in the 30-39 TBSA group to 26  in the 90-100 TBSA group; p<0·0001). Burn size of 62 TBSA was a crucial threshold for mortality (odds ratio 10·07, 95 CI 5·56-18·22, p<0·0001). Interpretation: We established that, in a modern paediatric burn care setting, a burn size of roughly 60 TBSA is a crucial threshold for postburn morbidity and mortality. On the basis of these findings, we recommend that paediatric patients with greater than 60 TBSA burns be immediately transferred to a specialised burn centre. Furthermore, at the burn centre, patients should be treated with increased vigilance and improved therapies, in view of the increased risk of poor outcome associated with this burn size. Funding: Shriners Hospitals for Children, US National Institutes of Health, US National Institute on Disability and Rehabilitation Research, Institute for Translational Sciences, CFI Leaders Opportunity Fund, Physicians' Services Incorporated Foundation.
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