Burns have aroused extensive public health concern and institute a global public health problem [1]. Burn injuries are common in children as thinner skin tolerates less heat at a shorter duration before full-thickness injury occurs [2]. Burns have been identified as one of the most devastating causes of child injury in terms of functional, social and psychological impairment [1]. The aim of treatment in burn injury is to control infection and promote healing with good aesthetic results. To achieve these goals, a wide variety of wound care products are currently available [3]. But the best method of treatment is yet to be determined. One of the primary problems in the management of burns is a bacterial infection which delays healing, increases pain, and the risk of scarring [2]. Topical management of burns is a challenging task. There are many reported methods regarding management of burn wounds. Open or exposure, semi-closed or closed techniques, with or without antibiotics all have been advocated. But with the evolution of newer techniques impetus of management is towards closed dressing with newer type of dressings [4]. The ideal management of burn is an economical, easy to apply, readily available dressings or method of coverage that will provide good pain relief, protect the wound from infection, promote healing, prevent heat and fluid loss and wait for spontaneous epithelization of superficial partial thickness burns [5]. Silver has remained the preferred topical agent for burn dressings for over 200 years and its antimicrobial properties have been known since ancient times [3,6]. Silver sulfadiazine (SSD) was introduced in the 1970s, when silver was complexed to propylene glycol, stearyl alcohol, and isopropyl myristate. Antibiotic sulfadiazine was added to this complex; hence the inhibitory action of silver and anti-bacterial effect of sulfadiazine was combined into a single product. This reduced the frequency of application of the drug to twice daily. This silver complex acted on the bacterial wall in contrast to the silver ions which acted on the bacterial energy system [4]. However, various side effects such as tissue irritation, inactivation by wound fluid and pseudoeschar formation has led to the decreasing popularity of the conventional products such as Silver sulfadiazine (SSD) cream [7]. But, SSD is still considered the standard antimicrobial treatment for burn wounds in many parts of the world [3]. The use of a biologic wound covering in pediatric burns reduces the number of dressing changes and minimizes all components of standard burn therapy. By protecting the wound, a biologic dressing may accelerate healing and decrease the development of a hypertrophic scar [8]. A biological dressing like collagen is a unique protein with a triple helical structure, and each helix has over 1000 amino acids. The main type of collagen in the skin is Type I collagen. Chemically, bovine collagen is very similar to the human form. Collagen sheets are produced from bovine tissues comprising mostly Type I and III collagens. For these reasons, collagen sheets are well qualified for use as an effective wound cover. Granulation tissue developed at a normal rate and the cellular events were precisely the same as those occurring in normal wounds[9]. Biologically, the collagen sheet is noninflammatory, nontoxic, has low antigenicity, has minimal degradation, facilitates migration of fibroblasts and microvascular cells, and helps in synthesis of neodermal collagen matrices, thus minimizing scarring. Physiologically, it is elastic, soft, supple, and has good tear strength. It is impermeable to bacterial migration, modulates fluid flux from the wound, and has enough strength to be peeled off from the wound. The cost of a single collagen sheet is more than SSD cream dressing. However, the cost factor comes down, and the pain associated with dressing can be avoided [9]. Daily dressing in the pediatric age group is painful and requires anesthesia. The cost incurred by both the parents and the hospital associated with multiple dressings can be avoided by a single collagen dressing. It is especially useful in children since the psychological trauma to the child and parents are minimized [2]. Considering the above mentioned facts of SSD and collagen dressing, the present study was carried out to compare the effectiveness of both dressing materials in superficial burn in children.

This was a prospective comparative interventional study carried out on patients admitted with superficial burn within 24 hours at Bangladesh Shishu Hospital & Institute, from March 2020 to March 2022. Total 40 patients were included in this study with up to 20% body surface area burn. The patient with any comorbidity, known allergy to collagen and SSD and electric and chemical burns were excluded from the study. They were randomly assigned to a collagen group (Group A = 20) and silver sulfadiazine (Group B = 20). The comparative parameters between two groups were time taken for effective pain relief (faces scale), time required for wound healing, wound infection and length of hospital stay. After discharge each patient was followed up weekly up to 1 month and each follow up healing, scar and itching were monitored. The statistical analysis was conducted using SPSS (Statistical Package for Social Science) version 26.0 statistical software. The student t-test and Mann Whitney U test were used to compare the continuous variables. Pearson’s Chi-square test was used to compare categorical variables. A p value of <0.05 was considered significant. The collagen membranes are available in various dimensions such as 5 cm × 5 cm, 10 cm × 10 cm, and 25 cm × 25 cm. The thickness of these collagen membranes is 0.6 mm. Under strict aseptic precautions, the burn wound must be first washed thoroughly with normal saline. Necrotic tissue and dead skin are removed from the burn wound. To wash off the preservative agents, collagen should be thoroughly washed with normal saline, and then, collagen dressing is applied over the wound, trimming with the scissors so as to cover the entire area. Within 1 hour, the membrane dries and becomes adherent to the wound [3]. Silver sulfadiazine is available in a 1% solution suspended in a water-soluble base. 1% silver sulfadiazine cream is used for the topical application over the burn wounds. Under strict aseptic precautions, the burn wound must be first washed thoroughly with normal saline. Necrotic tissue and dead skin are removed from the burn wound. Application of 1% silver sulfadiazine cream twice daily till wound healing.

At the end of follow up, a total of 20 participants in each group were included in the final data analysis. After completion of the data analysis, the results were organized in the tabular form Table 1 and 2. Figures 1-4 showed the comparison between pre and post results of the two groups of patients.

Table 1: Characteristics of the participants between two groups (n = 40)

Table 2: Comparison of variables between two groups (n = 40)

Figure 1: Superficial Partial Thickness Burn with Collagen Dressing

Figure 2: Superficial Partial Thickness Burn Without Collagen Dressing

Figure 3: Superficial Partial Thickness Burn with Collagen Dressing

Figure 4: After 10 Days of Collagen Dressing

A prospective study was conducted at the department of Burn and Reconstructive Surgery, Faculty of Paediatric Surgery, Bangladesh Shishu Hospital & Institute, Dhaka from March 2020 to March 2022 to compare the outcome between collagen dressing and silver sulfadiazine cream for the management of superficial burn in children. Total 40 patients who fulfilled the selection criteria within the assigned time were enrolled in the study. 20 participants were included in group A (Collagen group) and 20 participants were included in group B (Silver sulfadiazine group) after randomization. In this study, the independent variables were age, sex, body weight, percentage of burn and causes of burn. These variables were not statistically significant between the two groups. So, they did not have any effect on the outcome of the dependent variables. Majority of the patients were found in the 0-19 months’ age group, where 10 (50%) in collagen and 8 (40%) in the SSD group. Mean age of the study subjects in the collagen group was 28±22.2 and in the SSD group was 29.3 ± 22.1. There was no significant difference in age between the groups. The age range was 6 months to 96 months. In the epidemiological study of burn in children of Bangladesh they found the median age of childhood burn was 3 years which is similar to the findings of present study [1]. In this study female patients (52.5%) were slightly higher than males (47.5%). In several studies, it was shown that females are more prone to burn, especially from household burn. Likewise, in the study the incidence of burn was more in females (male: female = 0.66:1) [10]. The mean weight of the patients in the collagen group and SSD group was 14.1±7.3 kg and 13.6±6.6 kg without any significant difference. The range of weight was 6.5 kg to 39 kg. Weight was required to be measured for appropriate fluid management of burn patients. The main cause of burn was spillage of hot liquid (87.5%) in both groups without any significant intergroup difference. Cooking related burns occurred in 5 (12.5%) cases. In the study of Mashreky, et al. [1] hot liquid spillage is the second most common cause of childhood burn while flame burn was the most common cause. This discrepancy may be due to the fact that only superficial burn was included in this study and scald due to hot liquid spillage mostly cause superficial burn [1]. Percentage of burn was calculated by Lund and Browder chart. The mean % of TBSA in the collagen group and SSD group was 9.9±3.4 and 10.8±3.1 without any significant intergroup difference. The % of TBSA ranges from 5% to 18%.In the study of Singh & Bhatnagar [3], mean burn % of TBSA was 8.1% which is similar to the present study. As in both the studies, burn <20% TBSA was included, the mean % of TBSA is less accordingly. The mean duration of burn to hospitalization in collagen group and SSD group was 12.9±6.8 hours and 12.4±6.2 hours without any significant intergroup difference. Similarly, as the inclusion criterion of this study was burned within 24 hours of presentation, the mean time for hospitalization was only 12.6±6.4 hours. In the collagen group, mean pain relief time was 2.7±0.6 days while in the SSD group was 4.8±0.4 days which was significantly more than the collagen group (p-value<.001). This can be attributed to less frequent dressing change and early healing in the collagen group. The decreased pain associated with collagen dressing was also observed in the study of and [3, 11]. In the SSD group twice daily dressing was done and each dressing change involved manipulation of raw, sensitive skin surface, leading to pain and discomfort. In the collagen group most cases had a single dressing after collagen sheet application, and with epithelialization, residual collagen gets spontaneously removed. Moreover, collagen when used over the raw area provides the coverage for sensitive nerve endings, thereby diminishing the degree of pain significantly [12]. The mean time needed for wound healing in the collagen group was 7.3±1 days while in the SSD group was 10.3±1.8 days which is significantly higher (p<.0001). The overall range was 6 days to 13 days. This finding coincided with the finding of and where the collagen dressing group healed earlier than the SSD group [10, 12]. The orderly ingrowth of epithelium needs a layer of collagen to act as the scaffold on which it grows and arranges itself. Denuded areas are unable to provide this effectively, leading to the formation of extensive scars and even keloids. The intact epithelium provides a protective layer over cutaneous nerves; otherwise, these areas expose the nerves and cause pain and tenderness. It is for these purposes that denuded areas need a temporary cover until such times that the body is able to manufacture a cover of its own [12]. In the collagen group, there was no instance of infection while in the SSD group, only 1 (5%) case has developed infection. In the present study, injectable antibiotics were given for 3 to 5 days in all patients. Moreover, standard wound dressing protocol was followed in all patients. So, the infection rate is low. In the studies of [12] and [5] ^the infection rate was similar to the present study. The mean hospital stay in the collagen group was 4.5±0.6 days while in the SSD group was 6.8±0.7 days which is significantly more (p<.0001). Shorter admission in the hospital was recorded by several authors in the collagen group [5,11-13]. The reduced requirement for change of dressing, early pain alleviation and faster wound healing all are attributed to shorter hospital admission in the collagen-dressing group. In the present study, it was tried to avoid biases by taking a similar type of patient group. This is evident from the result that all independent variables are similar in both groups. Among the dependent variables, the collagen group has early pain relief, faster healing and shorter hospital stay in comparison to the SSD group.

Limitations of the Study: The study was conducted in a single hospital with a small sample size. So, the results may not represent the whole community.

Application of collagen dressing in superficial burns in children is more efficacious than 1% silver sulfadiazine in terms of early pain relief, faster healing and shorter hospital stay.

Key Findings

Key findings include: a prospective study comparing collagen and 1% silver sulfadiazine dressings in 40 children with superficial burns; collagen group showed significantly shorter mean pain relief time (2.7±0.6 days vs. 4.8±0.4 days), faster wound healing (7.3±1 days vs. 10.3±1.8 days), and shorter hospital stay (4.5±0.6 days vs. 6.8±0.7 days) compared to silver sulfadiazine group.

What is Known and What is New?

The known aspect is the use of various wound care products for the treatment of superficial burns in children, with the aim of controlling infection and promoting early healing. The new contribution is the comparative evaluation of collagen dressing and 1% silver sulfadiazine, demonstrating the superior efficacy of collagen in terms of pain relief, faster wound healing, and shorter hospital stay in pediatric superficial burns.

What is the Implication, and What Should Change Now?

The implication is the potential of collagen dressings as a superior treatment option for superficial burns in children, offering faster pain relief, accelerated wound healing, and reduced hospital stay compared to the commonly used 1% silver sulfadiazine. Changes needed include wider adoption of collagen dressings in burn management protocols and further research to validate these findings in larger patient populations.

Funding

No funding sources.

Conflict of Interest

None declared.

Ethical Approval:

The study was approved by the Institutional Ethics Committee of Bangladesh Shishu Hospital & Institute.

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