A Critique Paper on:

Pediatric Burn Treatment Using Tilapia Skin as a Xenograft for

Superficial Partial-Thickness Wounds: A Pilot Study

Submitted by:
MACEDA, Danela Kayla T.
MARTIRES, Mikaela Isabell D.
PETEL, Naomi Jeanne B.
SERAFICO, Jon Paul B.
UY, Micah Paulene O.

Submitted to:
Rosario R. Rubite, PhD

Submitted on:
December 27, 2022

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 I. Introduction

The study, “Pediatric Burn Treatment Using Tilapia Skin as a Xenograft for Superficial
Partial Thickness Wounds; A Pilot Study” by Lima Jr. et.al began by providing a thorough
background on the prevalence of burn especially the partial thickness type of burn as a common
cause on non-fatal injury among the pediatric age group ranking fifth worldwide.

The paper then gave a sufficient discussion of the currently used treatment modalities for
burn wounds. The most common practice mentioned in Brazil and worldwide is the use of Silver
containing creams such as Silver Sulfadiazine which however is associated with possible mild
side effects such as allergic reactions, hemolysis and methemoglobinemia (Fuller, 2009).
Another option would be the use of bioengineered approaches such as incorporating scaffolds,
stem cells and growth factors. Although highly promising, it proved to be not feasible in low and
middle income countries due to its cost (Elmasry, et. al., 2016). Another choice would be the use
of cadaveric allograft skin and allogenic amniotic membrane. However the problem was the risk
of microbial and viral contamination despite protocol adherence (Atiyeh, et.al., 2005).

This is why xenografts were considered to be a superior choice to allografts for increased
safety and reduced cost. There were a variety of species used in some studies such as pig, cow,
dog, chicken and rabbit but they were associated with decreased effectiveness due to complicated
preparation methods.

The problem statement therefore is clear and that is to find a better alternative treatment
for burn. Hence, the use of tilapia skin became its focus of study. The problem provided is
definitely researchable since the use of Nile tilapia (Oreochromis niloticus) skin carries the
promise of innovation from previous studies. It will also be easily investigated since burn as
mentioned previously is a common incident worldwide and Nile tilapia is a fish that is
distributed widely in the tropical and subtropical regions.

In order to further investigate the problem statement, the type of study that was employed
is experimental. According to Bhat (n.d.), an experimental research is a research conducted with

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a scientific approach using two sets of variables. It is vital that one of the two setups involved in
this type of research design serves as a constant in order to measure the difference in quantifiers
involved in the achievement of research objectives. For this research, the primary outcome
variable was the number of days to complete burn wound healing. This was calculated via
clinical judgment from the consultant and the number of dressings performed. In the control
group, the dressing change occurred daily, whereas the dressing change in the test group did not
have a fixed time and was heavily dependent on the necessity for change, according to the
patient’s clinical evaluation. By manipulating how dressing changes were conducted in the group
that used 1% silver sulfadiazine cream and the group that utilized tilapia skin, the relationship
between the variables of interest used in the study were clearly identified, calculated and
compared. As a result, researchers would subsequently be able to reject or accept the hypothesis
they have made; thus quantifying this study as an experimental research design.

Aside from comparing the number of days to complete burn wound healing between the
experimental and control groups, another variable that is of a discrete category is the total
amount of anesthetics and analgesics required throughout the treatment. However, unlike the
aforementioned variable, other secondary variables of interest such as pain assessment and
assessment of illness improvement on the day of dressing removal are operationally defined.
These variables were defined in terms of the Faces Pain Scale Revised and the Clinical Global
Impression Scale respectively.

The hypothesis of the study is that Tilapia skin is a feasible biomaterial or xenograft for
partial-thickness burn treatment of pediatric patients aged 2-12. This was based on 3 qualities: it
is a noninfectious microbiota, its morphological structure is similar to that of human skin, and it
has a large composition of type I collagen. It is an effective and well-rounded hypothesis because
it is a prime example of the method of multiple hypotheses, which allows the study to evaluate
the premise from different angles (Refaat, 2015). This is mainly through its comparison with a
control group that utilizes Silver Sulfadiazine 1% cream to treat burn patients. This enhances the
data as there is a basis of reference that can serve as a relative comparison to the traditional and
most commonly used method in Brazil, the country involved in the study. With this, the
hypothesis can be proven false, which amplifies its testability—an important quality to harbor.

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The hypothesis proved to be testable as the researchers translated their claim into an experiment.
The results could validate that Tilapia Skin is a cut above the regular treatment, or it could
disprove this by favoring the silver-based cream. Furthermore, the hypothesis is replicable for
future studies and applicable to real-life medical scenes, continuing the cycle of experimentation
and validation or disapproval.

Moving forth, the significance of the study, although not stated explicitly in one section,
is implied dispersedly throughout the paper. In line with its problem statement, the research
provides a thorough background on burns and their occurrences in pediatric patients. This
allowed readers to grasp the ubiquity of the issue and the gravity of finding the most efficient
method of healing burn wounds. As mild side effects of conventional treatment using Silver
Sulfadiazine cream were discussed, the need for a superior burn treatment was suggested as
various alternatives were considered with xenografts emerging as the most ideal one. Moreover,
the paper noted how Nile tilapia is regarded as Brazil’s most cultivated fish and fourth
worldwide. This expounds on the resourcefulness of tilapia skin as a burn treatment, adding to
the study’s findings of its advantages in terms of adherence to wound bed, frequency of dressing
changes, and amount of anesthetics required. Hence, it can be said that the researchers
successfully established a compelling stand on why such study should be conducted.

II. Main Analysis

Literature Review

The study is a pilot study which is defined as a small-scale test of method and procedure
(Porta, Dictionary of Epidemiology, 5th edition, 2008). Its purpose is to assess the feasibility or
acceptability of an approach to be used in a larger-scale study. It is a requisite initial step in
exploring a novel intervention (Leon, et. al., 2011). In this study there were only two literatures
cited about the use of tilapia skin as treatment for burn. It consists of a case study and the other
one was done on animal subjects. They were discussed very concisely in the last two paragraphs
of the introduction. Both of them showed results that were relevant to the problem under
investigation.

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 The first one was an in-vivo study using rats (Rattus norvegicus) with induced full
thickness burns treated with tilapia xenograft by Lima et. Al in 2017. The study showed that
Tilapia skin has good adhesion to the bed of wounds and had promoted cutaneous wound
healing. This allows continuation of investigation in human beings to confirm its safety and
efficacy. Likewise, a single case study report with a 3 year old pediatric patient with 18% total
body surface area w/ superficial thickness burn treated with tilapia skin as occluding dressing
showed good adhesion to the skin, and was discharged from the hospital after 10 days with
complete re-epithelialization and no reported adverse effects.

Materials and Methods

The participants involved in the study were 30 children between the ages of 2 and 12
years, admitted at the local institution in a burn treatment center found in Fortaleza, Ceara,
Brazil. This study population is appropriate for the study given that it is a phase II study, which
generally consists of less than 50 participants. Patients were excluded if they manifest various
descriptions such as having a burn wound greater than 20% of total body surface area and the
presence of previous treatment of the current burn. Further participant deliberation ensures that
external factors that may affect the treatment of the patient are absent from the study.

Moreover, various measuring techniques were employed in assessing the outcome of the
treatment. First, clinical judgment from the consultant was done to evaluate the number of days
for the completion of burn wound healing. Since the consultants conducted the treatment on
specific patients, they are the appropriate and reliable authority to accurately provide this
information. Second, the Face Pain Scale-Revised measuring technique was employed for pain
assessment. Depending on the patient’s age, the patients themselves or the caregivers of the
patients performed this pain assessment. The patients’ pain was evaluated using a scale of six
faces, each depicting a different degree of pain, thus making it appropriate for the study. Third,
the Clinical Global Impression Scale-Improvement was utilized for the assessment of illness
improvement on the day of dressing removal. This measuring technique was appropriate for the
study since the physicians responsible for each patient performed this pain assessment by using a

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scale to evaluate the improvement of the patient’s condition from admission to after the
treatment. Furthermore, to measure and analyze different variables, various statistical tests were
used. The Shapiro-Wilk test was used to verify the normality of the distribution of values. The
unpaired t-test (for parametric data) and Mann-Whitney U test (for nonparametric data) were
used to compare the silver sulfadiazine group and the tilapia skin group. With regards to
categorical variables when comparing the two treatments, the chi-square test was employed. As
for descriptive statistics, mean and standard deviation were used for parametric data, and median,
interquartile range, and minimum and maximum values were used for nonparametric data. The
aforementioned statistical methods were appropriate for the study since it involves the
measurement of quantitative data and variables. Through these methods, the researchers were
able to accurately analyze the data gathered.

Ethical considerations, particularly autonomy, were addressed in the study. The study
protocol and informed consent were approved by the local Institutional Review Board in Ceara,
Brazil. Prior to the procedure, each participant’s caregiver was given informed consent and
specific details concerning the study were explained to them.

From the title itself, it can be noted that this study is only limited to superficial
partial-thickness burn wounds. These burns are characterized by blisters that appear between the
epidermis and dermis within 24 hours. Those who are subjected to these types of wounds may
experience pain with pressure, pigment changes with minimal to no functional impairment or
hypertrophic scarring. In children, the Lund-Browder chart is the most recommended method in
assessing TBSA of the burn. TBSA is more accurately estimated using the Lund-Browder chart
as children have proportionally larger heads and smaller lower extremities. Still, given that this
study is focused on treating superficial (first degree) burns, according to a study conducted by
Dr. Philip J. Rice, an instructor in Harvard Medical School, superficial burns are not included in
the percentage of TBSA assessment, thus the Lund-Browder can not be applied to this particular
study. Although there has been no studies that were found to have utilized similar methods and
variables in determining the effectiveness of an alternative burn treatment, a conclusion can be
derived that the researchers made a good decision to make use of the number of days to complete
burn wound healing as the research’s primary outcome variable.

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 Moreover, this notion can be further proven by the study entitled “Treatment of
superficial burns requiring hospital admission” (2021), that states that after initial assessment
and cleansing, burn wound management for superficial partial-thickness burns is best conducted
by covering the wound with a topical agent or dressing. This dressing ultimately aids in skin
healing and re-epithelialization. Still, due to the accumulation of fibrinous exudates and
necrotic debris, heavy bacterial colonization and delayed healing may occur (Rice, 2021). As
such, researchers are faced with the challenge of achieving the balance between controlling the
exudate whilst not interfering with the wound re-epithelialization. For this research, they were
able to take into account this particular issue properly, especially with regards to the treatment
for the test group, by changing the dressings whenever they become soaked with excessive
exudate or other fluids or if there are signs of infection, and most importantly by also including
clinical judgment from consultants in their criteria.

Additionally, in contrast with other pilot clinical studies and treatments, one of the main
factors that researchers also had to take into consideration in designing their study is the age
demographics of those who will be undergoing the experiment. Some central issues of evaluating
pediatric pain are the poorer and less well-developed linguistic skills in younger children as well
as the abstract concept of pain that can be varied among children due to the strong emotional and
motivational connotations alongside it. Among the various pain assessment tools used widely in
medical treatment and research, the Faces Pain Scale has not only manifested its validity in
measuring pediatric pain, but it can also be adequately comprehended by younger children
(Hunter et.al, 2000).

Lastly, the Clinical Global Impression Scale- Improvement or CGI is also a reliable and
accurate tool in measuring burn improvement as substantiated by a study made by Michael Berk
and company (2008). Their findings suggest that the CGI is suitable for routine use in an
inpatient setting and can even bear numerous advantages such as established utility in psychiatric
research, sensitivity to change, quick and simple administration, utility across diagnostic
groupings, and reliability in the hands of a skilled clinician.

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 Overall, from the demographics of the participants to the preparation of the Nile Tilapia
Skin xenograft to how the variables of interest in the study were to be measured, the research
paper was able to clearly articulate the steps they have taken to conduct the said experiment,
consequently making it easy to replicate by other researchers. Despite having the patient’s pain
assessment and even the assessment of burn improvement be somewhat tainted by bias from
either the parent, patient or the attending physician, the inclusion of discrete quantitative
variables such as number of days until re-epithelization and total amount of anesthetics and
analgesics required throughout the treatment, would eventually offset the possible biases
previously mentioned.

Presentation and Interpretation of Results

The presentation of results was divided into 6 subcategories that contribute to the
research problem and objective. These subsections clearly divided with headings in a bigger font
compared to the body are as follows: demographic characteristics, time to re-epithelialization,
evaluation of burn improvement, pain assessment, anesthetics and analgesics intake, and the
number of dressings performed. The order seamlessly transitions from the pool of participants to
the categories not affected by the independent variable to the categories that are. As the heading
of each category was self-explanatory, only a direct and concise description was given
encapsulating its essence. Along with this, the statistics for each variable studied were
enumerated with the corresponding test used to reach the conclusion. A brief explanation of
whether the variable significantly changed in response to the new treatment was stated in relation
to the statistical values. Given this, each table and graph was explained in the text in a concise
manner.

However, the graphs and tables corresponding to the subdivisions are positioned in an
incoherent manner. Although labeled properly, the figures do not directly follow its worded
explanation as the two-column format does not merge well with the long charts. Additionally, it
may be difficult to track which values correspond to which names as the tables do not contain
lines or color-coded formats to make the numerical values easily distinguishable. Moreover, the
paper lacked consistency in font and font size as figure 1, under the category of time to

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re-epithelialization. This disrupted the aesthetics of the overall paper. Another aspect that can be
improved is that the graphs and tables did not have a titular statement, and instead included a
long explanation of its content. This makes it tedious for the reader to immediately grasp and
understand it.

Despite the lack of an easy-to-follow flow between text and figures, the information
aspect of the figures was sufficient and heavily relevant to the research. The parametric methods
utilized suited the objectives of the study as they accurately drew out the conclusion that would
benefit the field. It proves the thoroughness of the study as different impacts were observed and
recorded to achieve its well-rounded nature. It was not too extensive wherein the viewer may
lose focus on the essence of the study. It was also not too concise that the information would be
lacking. In fact, it did not leave holes for misinterpretation which overall, created an
easy-to-understand research paper apart from its layout or organization.

Discussion of the Findings

The discussions of the article did not particularly match the organizational direction of
the results. It commenced with the subsections with significant improvement from the
experimental setup. However, this did not make the paper feel incomplete; rather, it paid
attention to the important points and focused its discussion around this. More specifically, the
number of dressings and amount of anesthetics were discussed. Additionally, the benefits of its
decrease were not divorced from its effects on the safety and well-being of the patients. They
continued the research by describing the enhanced functional recovery process under the Tilapia
Skin methodology. The paper also touches on the negative environment of the current healthcare
system as the standard treatment involves silver sulfadiazine, solidifying the need for a new
treatment.

From an aesthetic and layout perspective, the discussions, conclusions, and

recommendations are not separated by headings, which made it difficult to distinguish where one
ended and the other started. Additionally, the tables and charts from the results overlapped with

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the text of the discussions. This merge contributed to the confusion one might feel as references
were not made to the specific figures on the page of the discussions.

Moreover, the tables present in the paper were well-organized and placed below the text
that referred to it, making it easily accessible to the readers. However, as previously mentioned,
the placement may also contribute to the confusion of readers due to its merged placement with
the text. Furthermore, these tables and figures were explained in specific paragraphs in the paper,
however, the information provided may not be sufficient enough to comprehend the statistical
data if one has no prior knowledge on various statistics concepts. Data, information, and graphs
presented in the tables were properly labeled, and additional information regarding the table may
be found above or below the table itself. There are legends present at the bottom of each table to
provide further information about the definition of abbreviations on the table.

Overall, the findings discussed were in view of the research hypothesis and were suitable
for the premise of the study. It covered the bases in which the experimental set-up showed
significant benefits to the patients compared to the cream. However, they did not study nor
discuss the negative effects of Tilapia Skin as xenografts, which could mean a biased or
one-sided study. Additionally, the theoretical and practical implications of the research data were
discussed in the text under the discussion label on the paper. The researchers explained the
correlation of the number of dressing changes with effects on patients’ wellness, as well as the
implications of reduced requirement for anesthetic medication and abundance of dressing
materials and topical treatment.

III. Conclusion

The study’s findings demonstrated the advantages of Nile tilapia skin in comparison to
Silver Sulfadiazine cream as a burn treatment. Specifically, it presents tilapia skin treatment as a
resource-efficient method supported by its superior medical performance illustrated by its
absence of allergens, good adherence to the wound bed, reduced number of needed dress
changes, and decreased amount of required anesthetic intake. This, in turn, improved the healing
process and minimized overall workload, essentially benefitting both patients and healthcare

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workers alike. With that being said, the study’s objective to evaluate the efficacy of Nile tilapia
skin as a xenograft was sufficiently met as it was proven to have multiple advantages compared
to the current treatment being used. It then accordingly concluded that tilapia skin serves as a
promising extra low-cost and effective resource for the therapeutic treatment of pediatric
superficial partial thickness burns.

As mentioned previously, the study is a pilot study. Thus, it paves the way for prospective
opportunities involving larger-scale examinations to be conducted. As such, the study’s
execution and results may be further refined and enhanced for more in-depth studies. Therefore,
it is commended how the paper distinctly indicates its known limitations for future studies to
work on. Due to its relatively small-scale implementation, there is uncertainty in determining the
study’s external validity. Moreover, the inability of the experimental group to be oblivious to the
unique treatment and the low number of patients involved may have influenced the results in
certain aspects. Notably, the researchers also disclosed and accounted for difficulties in applying
tilapia skin to some anatomical locations such as the face, genitals, neck, etc. As can be seen,
these limitations directly confront the bounded scope and extent of the study, whilst
constructively giving suggestions for other researchers to consider. With that, the paper
acknowledges and addresses its lacking aspects for supplementary research to tackle by
providing preliminary data adequate for larger randomized clinical trials.

Recommendations

To further examine the efficacy of tilapia skin as a xenograft for burn wounds, it is
recommended that the treatment should be tested on a larger study population. This study was
only conducted on a relatively small study population from a single medical center, thus in order
to determine the external validity, the treatment may also be tested on populations from various
medical centers in and out of Brazil. Furthermore, it is suggested that comparison studies on
tilapia skin treatment and other occlusive dressings and xenografts may be conducted in order to
determine the best possible treatment method for different cases of burn wounds. Finally, given
that the reduced cost of the use of tilapia skin was only a hypothesis, an extensive cost-benefit

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analysis on the use of tilapia skin as a xenograft may be done to assess the various advantages
and disadvantages of this particular treatment.

Overall, the findings of this study are highly relevant to the Philippines since there are
currently high cases of burn wounds and injuries among the pediatric population. According to a
study conducted by Dr. Tan et al. on the profile of patients admitted to the University of the
Philippines - Philippine General Hospital Alfredo T. Ramirez Burn Center from 2013 to 2015,
24% of the patients were less than 1 year old and 25% were 2 to 14 years of age (Tan et.al.,
2017). Moreover, tilapia may be found in various parts of the Philippines, with Pampanga,
Batangas, and Pangasinan being the top producers (PCARRD, n.d.). The most common species
of tilapia found in the country is Nile Tilapia (Oreochromis niloticus), which is the species used
for this study. Given this, using tilapia skin as a xenograft for burn wound treatment may be
extremely beneficial to the community as the current admission cost based on hospital bills for
burn injuries is around Php6,521.53 (Rivera et.al., 2018). With the discovery of tilapia skin as a
burn wound treatment, costs may significantly decline.

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IV. References

Atiyeh, B. S., Hayek, S. N., & Gunn, S. W. (2005). New technologies for burn wound closure
and healing--review of the literature. Burns : journal of the International Society for Burn
Injuries, 31(8), 944–956. https://doi.org/10.1016/j.burns.2005.08.023

Berk M, Ng F, Dodd S, Callaly T, Campbell S, Bernardo M, Trauer T. The validity of the CGI
severity and improvement scales as measures of clinical effectiveness suitable for routine
clinical use. J Eval Clin Pract. 2008 Dec;14(6):979-83. Doi:
10.1111/j.1365-2753.2007.00921.x. Epub 2008 May 2. PMID: 18462279.

Bhat, A. (2018, June 12). Experimental research - Definition, types of designs and advantages
QuestionPro. QuestionPro. https://www.questionpro.com/blog/experimental-research/

Elmasry, M., Steinvall, I., Thorfinn, J., Abbas, A. H., Abdelrahman, I., Adly, O. A., & Sjöberg, F.
(2016). Treatment of Children With Scalds by Xenografts: Report From a Swedish Burn
Centre. Journal of burn care & research : official publication of the American Burn
Association, 37(6), e586–e591. https://doi.org/10.1097/BCR.0000000000000379

Fuller F. W. (2009). The side effects of silver sulfadiazine. Journal of burn care & research :
official publication of the American Burn Association, 30(3), 464–470.
https://doi.org/10.1097/BCR.0b013e3181a28c9b

Hunter, M., McDowell, L., Hennessy, R., & Cassey, J. (2000). An Evaluation of the Faces Pain
Scale with Young Children. Journal of Pain and Symptom Management, 20(2), 122–129.
https://doi.org/10.1016/s0885-3924(00)00171-8

Leon, A. C., Davis, L. L., & Kraemer, H. C. (2011). The role and interpretation of pilot studies in
clinical research. Journal of psychiatric research, 45(5), 626–629.
https://doi.org/10.1016/j.jpsychires.2010.10.008

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Lima, E., Picollo, N., Borges de Miranda, M., Ribeiro, W., Alves, A., Ferreira, G., Parente, E., &
Moraes-Filho, M. (2017, June 1). Use of tilapia ( Oreochromis niloticus ) skin as an
occlusive biological dressing in the treatment of burns. Revista Brasileira De
Queimaduras.
http://rbqueimaduras.org.br/details/341/pt-BR/uso-da-pele-de-tilapia--oreochromis-nilotic
us---como-curativo-biologico-oclusivo--no-tratamento-de-queimaduras

PCAARRD. (n.d.-a). Tilapia Industry Profile. PCAARRD’s Industry Strategic Science and
Technology Plans. https://ispweb.pcaarrd.dost.gov.ph/tilapia-2/

Porta, M. (2008). A Dictionary of Epidemiology (5th ed.). Oxford University Press.

Rice, P.J, & Orgill, D.P. Assessment and classification of burn injury (2021) Jeschke, M.D, &
Collins, K.A. (Ed.)
https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury#H12

Refaat, S. (2015). Single vs. Multiple Hypothesis. Linked In.

https://www.linkedin.com/pulse/single-vs-multiple-hypothesis-shareef-refaat

Rivera, A. S., Lam, H. Y., Macalino, J. U., & Quebral, J. D. (2018a). Healthcare-associated
Expenses Due to Injuries in the Philippines. Acta Medica Philippines, 52(2).
https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/424#:~:text=Results
.,intentional%20injuries%3A%20PhP8%2C023.00

Tan, A. M. L., Cruz, J. J. V., & Nable-Aguilera, M. A. A. (2017a). Profile of Patients Admitted in
the University of the Philippines - Philippine General Hospital Alfredo T. Ramirez Burn
Center From August 2013 to July 2015. Philippine Journal of Surgical Specialties, 72(2).
https://pcs.org.ph/wp-content/uploads/2022/03/PCS-v72-no2-1-profile_patients1.pdf

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Tennenhaus, M. Rennekampff, H.O. (2021). Treatment of superficial burns requiring hospital
admission.https://www.uptodate.com/contents/treatment-of-superficial-burns-requiring-h
ospital-admission/print?topicRef=819&source=see_link

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