Case Report

Case of extreme growth deceleration after burns

Cheryl Bline a, Maggie L. Dylewski b, Daniel N. Driscoll c,Gennadiy Fuzaylov d,*aDepartment of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 012114,

United Statesb Shriners Hospital for Children, Boston, MA 02114, United StatescHarvard Medical School, Massachusetts General Hospital, Boston, MA 012114, United StatesdHarvard Medical School, Department Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital,

55 Fruit Street, Gray/Jackson 409, Boston, MA 012114, United States

b u r n s 4 0 ( 2 0 1 4 ) e 1 5 – e 1 7

a r t i c l e i n f o

Article history:

Accepted 23 September 2013

Keywords:

Growth deceleration

Burns

Abuse

a b s t r a c t

Studies have demonstrated deceleration in both weight and height following burns in

children. It is expected patients will display catch up growth and return to normal weight

within three years but continued height deficiency may remain in cases of severe burns.

We describe a case of severe growth retardation of 8 years old orphan child from Ukraine

who suffered of burn less than 40% of total body surface area when he was a 3 years of life.

His case was complicated by domestic abuse, neglect and limited medical care. He initially

presented to the United States for surgical care of his contractures but his treatment quickly

focused on his profound growth retardation. Despite aggressive nutritional supplementa-

tion and evaluation he did not demonstrate any weight gain.

Published by Elsevier Ltd and ISBI

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

1. Introduction

Significant hypermetabolic injuries that occur during child-

hood can have significant effect on growth deceleration [1,2].

One example of a hypermetabolic injury is a burn. While

treatments may vary between locations, there is no difference

in the degree of metabolic alteration in patients who have

early excision and grafting of affected areas compared to

patients who have conservative therapy with the application

of antimicrobial ointments initially [3]. Studies have demon-

strated an initial deceleration in both height and weight with

burns [1,2,4]. Growth deceleration is more pronounced in

patients with severe burns and catch up growth has been

displayed in both height and weight regardless of burn

severity [1,2]. Weight returns to normal within 3 years

* Corresponding author. Tel.: +1 617 643 3416; fax: +1 617 726 9697.E-mail addresses: gfuzaylov@partners.org, gfuzaylov@yahoo.com

Abbreviation: HIV, human immunodeficiency virus.0305-4179/$36.00. Published by Elsevier Ltd and ISBIhttp://dx.doi.org/10.1016/j.burns.2013.09.013

post-burn but continued deficiency in height may remain in

patients with severe burn [2]. Patients with severe burns can

develop vitamin D deficiency that will result in decreased bone

mineral density and may affect bone growth [2,5]. Various

treatments have been suggested including vitamin D supple-

mentation, recombinant growth hormone and oxandrolone

[5–7]. Available studies evaluate patients who are in proximity

to their burn and who have received initial care in the United

States. We explore a case of a young Ukrainian male orphan

who is remote from his initial injury.

2. Case description

This report describes the medical course of an 8-year-old boy

who was brought to the United States from Ukraine for

(G. Fuzaylov).

Fig. 1 – Photo before (Panel A) and after (Panel B) treatment.

Table 1 – Longitudinal calorie, weight, and pre-albumindata.

Calorie intakekcal/day (kcal/kg)

Weight kg(z-score)

Pre-albumin(mg/dL)

Admission – 13.0 (�8.1) 12

1 month 2079 (160)* 13.6 (�7.6) 19

2 month 1944 (150)* 13.3 (�8.0)

3 month 1900 (146)** 13.8 (�7.4)

4 month 2100 (162)** 13.4 (�8.0)

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evaluation of severe burn contractures. Although his past

medical history is vague, between the ages of 2–3 years, this

patient suffered a flame burn to his face, chest, trunk, and

partial extremities while living at home with his biological

parents. It is estimated that the original burn covered less than

40% of his total body surface area was primarily full thickness.

Reports from social services in Ukraine, as well as dialog from

the patient suggest that his parents neglected his acute injury

and he endured domestic physical and emotional abuse. The

patient was eventually intercepted by Social Services and

placed in an orphanage.

Approximately five years after his burn and one year after

his placement in the orphanage, he was brought to the United

States for treatment at a pediatric burn hospital. His primary

diagnoses included burn scar contractures and malnutrition

(Fig. 1). The right elbow and bilateral knees were severely

contracted and the left arm was adhered to his chest and

abdomen. He was wasted, stunted and non-weight bearing.

An oral examination revealed multiple dental carries of the

primary teeth with visible odontogenic infections. Outside of

his physical, nutritional limitations, remaining components of

the physical exam were unremarkable.

Admission weight (13 kg), height (109 cm) and BMI (10.9)

were below the 5th percentile on the Center for Disease

Control age specific growth charts. Bone density, assessed

using dual energy X-ray absorptiometry indicated severe

osteopenia at the lumbar spine (z-score = �3.2). The prealbu-

min level (12 mg/dL) was also depressed. Complete blood

count, electrolytes and liver function tests were all within

normal limits. He tested negative for HIV and intestinal

parasite.

The child’s significant malnutrition delayed surgical

reconstruction until nutritional status was restored. An

aggressive treatment plan, consisting of oral intake coupled

with enteral nutrition support via a nasogastric feeding tube

was devised.

Protein and energy goals were titrated to support weight

gain and restore visceral proteins. Initially protein require-

ments were estimated to be 2–3 g/kg and the caloric goal was

1400 kcal per day, calculated using the dietary reference intake

value plus an additional 500 kcal. Multivitamin, calcium,

vitamin D and an anabolic steroid supplements were also

provided.

The patient tolerated enteral tube feedings and an oral diet.

Total caloric intake exceeded the initial goal by 35–50%

throughout admission (Table 1).

Visceral protein status normalized after 1 month of

aggressive nutrition support (Table 1). However, despite

aggressive nutrition therapy, significant weight gain was

never achieved (Table 1).

Surgical treatment, which consisted of releasing his left

arm from his chest, release of contractures in his other

extremities and skin grafting of open areas, was completed

without complications. He received daily physical therapy for

assistance with range of motion in all four extremities and

weight bearing activities. After 60 days, he was discharged

from the hospital.

As an outpatient, he continued aggressive physical and

nutritional therapy. He also received dental rehabilitation that

included of the removal of the infected primary teeth. Dietary

analyses revealed that his caloric intake was maintained at

approximately 1900–2100 kcal per day (Table 1). Celiac disease,

other intestinal malabsorption disorders, and hyperthyroid-

ism were all ruled out. Despite sustained and substantial

caloric intake and no clear evidence of a malabsorption

disorder, the patient failed to gain weight.

3. Discussion

The bodies of literature that discuss growth deceleration

and burns specifically discuss cases in which the children

are treated for acute burns with follow-up for several years

[1–4]. This is a unique case in which the child did not

present for aggressive treatment for several years after his

burn. Studies have yet to be completed to examine if there is

a time frame in which a child may be able to display catch

up growth. It is possible that the severity of this child’s

nutritional deficit and the duration of the deficit may have

long-lasting repercussions on his ability to achieve a normal

weight.

The ability to bear weight has also been important. Studies

have demonstrated reduction in linear growth in all burns

with a return toward normal once activity is resumed [2].

Demineralization has been demonstrated and can affect the

integrity of the child’s long bones. The severity of this patient’s

contractures, particularly in his lower extremities, prevented

weight-bearing activity. His total body surface area of his burn

did not fall in the category of a severe burn but several years of

b u r n s 4 0 ( 2 0 1 4 ) e 1 5 – e 1 7 e17

limited weight bearing may have resulted in permanent linear

growth retardation. His ability to regain length now that he is

participating in physical therapy with weight bearing will be

determined over the following years, but if his failure to gain

weight is any indication, he likely will have long-lasting height

deficiency.

Another factor that may have contributed to this child’s

dramatic growth deceleration is his social situation. Children

from abused and neglected households without serious illness

or injury can display growth delay [8]. The combination of

growth deceleration from years of abuse and neglect com-

bined with serious injury may have combined in this case.

In conclusion, it is expected that children with burns will

have a deceleration in height and weight growth with most

demonstrating catch up growth. It is uncommon for children

to present remote from their initial injury, but this could have

long-lasting effects on the ability to regain lost height and

weight despite aggressive nutrition supplementation and

physical therapy.

Funding source

No funding was received for this project.

Financial disclosure

Authors have no financial relationships relevant to this article

to disclose.

Conflict of interest

The authors declare that they have no conflict of interest.

r e f e r e n c e s

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[2] Prelack K, Dwyer J, Dallal G, Rand WM, Yu YM, Kehayias JJ,et al. Growth deceleration and restoration after serious burninjury. J Burn Care Res 2007;28:262–8.

[3] Rutan TC, Herndon DN, Van Osten T, Abston S. Metabolicrate alterations in early excision and grafting versusconservative treatment. J Trauma 1986;26:140–2.

[4] Childs C, Hall T, Davenport PJ, Little RA. Dietary intake andchanges in body weight in burned children. Burns1990;16(6):418–22.

[5] Klein GL, Langman CB, Herndon DN. Vitamin D depletionfollowing burn injury in children: a possible factor in post-burn osteopenia. J Trauma 2002;52:346–50.

[6] Aili Low JF, Barrow RE, Mittendorfer B, Jeschke MG, ChinkesDL, Herndon DN. The effect of short-term growth hormonetreatment on growth and energy expenditure in burnedchildren. Burns 2001;27:447–52.

[7] Murphy KD, Thomas S, Mlcak RP, Chinkes DL, Klein GL,Herndon DN. Effects of long-term oxandroloneadministration in severely burned children. Surgery2004;136:219–24.

[8] Olivan G. Catch-up growth assessment in long-termphysically neglected and emotionally abused preschool agemale children. Child Abuse Neglect 2003;27:103–8.