Initial Pediatric Burn Management: A Practical Guide

Abstract

Children have an imperative to explore their environment to grow and develop, which puts them at risk for sustaining burn injury. Burn injury remains the third leading cause of injury-related death worldwide. Plastic surgeons, as experts in the evaluation and management of cutaneous injuries, are frequently called upon to evaluate and treat children with burn injuries. This article focuses on the unique physiologic aspects of children and how they impact initial evaluation and management of burn injury. Children are not “little adults,” and they have different airway, circulatory, and cutaneous systems. Understanding the signs of potential child abuse is important to avoid further child harm. Finally, recognition of the criteria for referral to a pediatric burn center is important to optimize both short- and long-term outcomes for patients and families.

Worldwide, burns are third among the leading causes of childhood injury resulting in death. ¹ Each year approximately 416,000 people are treated for burn injury in U.S. emergency departments, including > 100,000 children with 300 children and adolescents succumbing from fire or burn injuries yearly. ^{2 3 4} Burn injury in children is bimodal, with approximately half of burn incidents occurring in children 1 to 4 years of age and another smaller peak as children become adolescents. ⁵ The management of children with burn injury is particularly challenging due to their variable cognitive, physiologic, and physical development. The treatment of a 2-year-old is markedly different than that of an 8-year-old or an adolescent. The majority of burns in children are small, yet even these small burns may have long-term effects on a child's development. Plastic surgeons are frequently involved in initial burn management, both large and small, due to the limited number of pediatric burn centers nationwide. The purpose of this article was to review initial burn management in children, focusing on unique aspects of care due to age and developmental differences between children and adults, to prepare the general plastic surgeon for caring for this challenging population.

Unique Aspects of Pediatric Physiology

Fundamentally, children are not “little adults,” as the child's major physiologic systems, including the skin, cardiovascular, pulmonary, and even metabolic system, are still developing. A child's airway differs from that of an adult in several ways. Unlike the adult, who has a tubular airway, a child's airway is cone shaped. As a result, the cricoid region is the narrowest portion of a child's airway. ⁶ In addition, a child's vocal cords are more anterior, the tonsils are larger, and the posterior pharynx is more perpendicular than in an adult, making intubation more difficult. All these factors combine to increase the difficulty in securing an airway in a small child. The smaller diameter of the pediatric airway causes increased susceptibility to obstruction due to edema, particularly after burn injury, as the cross-sectional area is proportional to the radius to the fourth power. Airway maturation continues for years after birth. For example, a child's bronchioles continue to develop until approximately age 8 years. This lack of development, combined with the increased incidence of reactive airway disease, can complicate management of smoke inhalation injury. Finally, children have a higher respiratory rate than adults, partially due to their baseline higher metabolic rate, and partially from the increased metabolic rate associated with burn injury. Hence, the “normal” respiratory rate in a severely burned child is often higher than age norms. Fortunately, children can compensate for respiratory issues; however, when they decompensate, they do so quickly and with little warning.

The cardiovascular system of a child also differs from an adult. Children have higher heart rates than adults. In very young children (< 2 years) cardiac output is rate-dependent, as the ability to increase contractility is limited. Hence, tachycardia is a compensatory response after injury. The high metabolic rate after burn injury often increases heart rate above norms for age. Hence, resuscitation after burn injury in children should NOT be guided by heart rate alone, as tachycardia is the norm in burned children and will not resolve with fluid administration. Bradycardia in an infant is often a harbinger of impending cardiorespiratory collapse and should be addressed promptly. An additional consideration is the impact of resuscitation on cerebral perfusion. The blood-brain barrier in a child is immature, making them susceptible to cerebral edema during aggressive resuscitation. Finally, children have immature immune systems which make them more susceptible to infection than adults.

The largest organ in the body, the skin, differs from that of adults in several areas. Overall, children have thinner skin, a greater body surface area per unit mass, and a different distribution of body surface area than an adult. This results in a more rapid development of hypothermia, as a greater surface is exposed after injury. In infants, the stratum corneum is thinner, water handling is different, and moisturizing factors as well as skin lipid production are reduced compared to adults, contributing to skin injury and inflammation. ^{7 8 9 10} These factors, combined with the child's curiosity and need to explore the environment, increase the risk for sustaining a burn injury. A child's thinner skin will develop a third degree burn at lower temperatures and over a shorter exposure period than for adults. Although wound healing in children follows the same physiological process as adults, their healing is accelerated. Fetal wound healing, which is essentially scarless, dissipates after birth, yet represents a potential avenue for future research into scar mechanisms.

Initial First Aid for the Child with Burn Injury

Management of a child with burn injury can be challenging, as both the child and the parent are often in a state of high stress. Initial first aid for acute burns in children starts with removal of the patient from the heat source. For example, if the child is scalded with hot water and still has wet clothing on, remove the clothes. Diapers, socks, and single piece pajamas can easily trap heated water and increase the burn injury. If the child presents within 3 hours of injury, irrigation of the wounds with cool tap water for 20 minutes has been shown to decrease burn depth and size. ¹¹ This will also assist in pain control. Wounds can then be assessed or placed in clean dressings (if available) for transportation to a physician's office, hospital emergency departments, or other acute care center.

Unique Aspects of Initial Pediatric Burn Management

Initial pediatric burn evaluation mirrors that of adults. Follow the A, B, Cs: assess the airway, breathing, and circulation for life-threatening issues. Smoke inhalation airway injury after burns falls into three main categories: (1) injuries due to inhalation of toxic gases, smoke, or hypoxia; (2) upper airway edema from heat exposure; and (3) lower airway injury due to toxic smoke exposure. Overall, children sustain inhalation injury at a higher rate than adults because they have limited mobility (babies have not learned to walk, toddlers are unsteady), they do not recognize the danger of the situation (immature cognition), or they are hiding because they started the fire. For assessment of type 1 injuries, that from gases, assuring adequate oxygenation and screening for other toxic gases such as carbon monoxide can be helpful. A pulse oximeter may not be accurate in smoke inhalation injury, as carboxyhemoglobin and oxyhemoglobin are not distinguished by the majority of pulse oximeters in current use. Measurement of arterial blood gases with co-oximetry and carboxyhemoglobin should be used to assess for oxygenation and smoke exposure. Any child with carboxyhemoglobin > 10% should be treated with 100% oxygen until carboxyhemoglobin levels are < 10%. Inhalation injury often is not apparent on chest radiographs on the day of injury. For smoke inhalation patients who remain acidotic after adequate fluid resuscitation, administration of hydroxocobalamin may be helpful to treat potential cyanide toxicity. ¹² However, hydroxocobalamin is associated with a higher risk of acute kidney injury and precludes hemodialysis for renal failure due to the colorimetric changes that accompany the treatment.

For type 2 inhalation injury, airway obstruction due to edema, careful history and ongoing physical examination for edema are essential. Endotracheal intubation may be necessary if a child becomes hoarse, develops stridor, has sternal retractions, or abdominal breathing. Serial evaluation of the airway is important, as edema develops over time. Endotracheal intubation should be performed by the most experienced provider using the appropriate size endotracheal tube. Type 3 inhalation injury is caused by particulates in smoke, with subsequent development of airway casts, reactive airways, and mucus plugging. Humidified oxygen, bronchodilators, and aggressive pulmonary toilet measures can help improve oxygenation and ventilation. Some centers use aerosolized heparin and acetylcysteine to decrease secretions, yet the benefits have not been confirmed in randomized multicenter trials. Serial bronchoscopy may be needed to clear tenacious secretions.

Children who have been burned become rapidly dehydrated due to the fluid losses from the burn wounds and overall loss of capillary integrity. Delays in resuscitation of as little as 30 minutes have been shown to impact outcomes. ¹³ Insertion of two large intravenous catheters, a central line, or in desperate situations an intraosseous line is essential to begin fluid resuscitation in children with burns > 20% total body surface area (TBSA). ¹⁴ There are numerous formulas available to help guide burn resuscitation in children. However, formulas are merely guides to aid in initiation of resuscitation. The volume of fluid administered should be adjusted hourly based on urine output (1 mL/kg/h in children < 30 kg and 0.5 mL/kg/h in children > 30 kg). The Advanced Burn Life Support Course recommends the following resuscitation guidelines:

Adults or teenagers (≥ 13 years old): 2 mL lactated ringers × kg × % TBSA burn = mL/24 h ÷ 16 = mL/h starting rate

Children (< 13 years old): 3 mL lactated ringers × kg × % TBSA = mL/24 h ÷ 16 = mL/h starting rate plus D5LR at maintenance rate

Remember to adjust intravenous fluid administration hourly based on urine output. If the urine output is below the goal, increase intravenous fluids by 10%; if above, then decrease by 10%. For example, in a 10-kg 18-month-old child with a 50% burn, the calculation would be:

3 mL × 10 kg × 50 (% TBSA burn) = 1500 mL/24 h ÷ 16 = 93.75 mL/h lactated ringers solution PLUS D5LR at 40 mL/h (normal fluid maintenance rate by the 4-2-1 rule in which the patient gets 4 mL/kg for the first 10 kg, 2 mL/kg for the second 10 kg, and 1 mL/kg for each subsequent kg). REMEMBER: adjust fluids hourly based on urine output.

Complications of fluid resuscitation in children mirror that for adults and include compartment syndrome (extremities, chest, abdomen), pleural effusions, cerebral edema, and elevated intraocular pressures. Intermittent intravenous analgesia and sedation should be used during the resuscitation phase, if at all possible, to avoid the fluid creep that accompanies continuous infusion of vasodilating agents.

Determination of Burn Wound Size and Extent

Children, as mentioned above, have a different body surface distribution compared to adults. Children 0 to 2 years of age have a larger head (approximately 18% of their TBSA) and smaller legs (approximately 14% TBSA per leg) compared to 9% for the head and 18% per leg in an adult. Determination of burn size in a child is readily done using either a Lund and Browder chart or employing the palm principle. ¹⁵ The child's palm, including fingers, is 1% of their body surface area. On a practical level, the surgeon can ask the child to do a “high five” to give them an estimate of the child's palm area. Technology is also being employed to assist in burn size estimation, utilizing various platforms such as smartphones, tablets, and body surface area scanners. The SAGE, Surface Area Graphic Evaluation, diagram (SageDiagram LLC) among others, is available online to assist in burn size calculation.

Burn extent, defined as burn depth, is key in burn size determination. Burn depth is determined by the level of heat and the duration of contact with the heat source. The hotter the source, the less time needed to sustain a third-degree burn ( Table 1 ). First-degree burns are restricted to the epidermis and are characterized by transient erythema that resolves within a few days. First-degree burns are not included in burn size estimation, as the skin retains its primary protective function. Second-degree burns extend through the epidermis into the dermis and are characterized by blistering and pain. Hair follicles are often visible in the base of the wound. Superficial second-degree burns heal within 10 days, while deep second-degree burns require 10 to 14 days to heal. Third-degree burns traverse the dermis and extend to the level of fat. In flame burns, the burn eschar appears white or leathery, while third-degree scald burns are deep nonblanching cherry red. These burns take > 14 days to heal and generally require excision and grafting to minimize scarring. Fourth-degree burns extend beyond the skin, involving soft tissues including muscle and even bony structures. Only second-, third-, and fourth-degree burns are included in the burn size estimation for resuscitation .

Table 1. Burn time and temperature chart ²⁸ .

Temperature	Second-degree burn	Third-degree burn
(Fahrenheit)	Time	Time
113	2 h	3 h
116.6	20 min	45 min
120	8 min	10 min
124	2 min	4.2 min
131	17 s	30 s
140	3 s	5 s

Initial burn wound management consists of washing the burn with soap and water, removing devitalized tissue, and applying a dressing. In children, special care should be taken to avoid hypothermia, as the greater surface area of the child predisposes them to hypothermia. With the exception of the palms of the hands and soles of the feet, blisters should be expressed, and loose tissue removed. Generally, blisters can be left intact on the palms and soles unless they are of sufficient size to cause pressure injury to the tissues beneath. Burns should be elevated above the heart to minimize burn edema formation. The choice of dressing depends on the characteristics of the wound, the interval between injury and presentation, family resources/ability to complete dressing changes, and the circumstances surrounding the burn injury. The most common organisms present in wounds within the first 2 weeks of injury are staphylococcus and streptococcus. Wounds that will take longer than 2 weeks to heal will probably need grafting and generally contain Gram-negative organisms. ^{16 17} If a wound is anticipated to heal within 1 to 2 weeks, application of a silver dressing (such as Mepilex Ag, Silverlon, etc.) for a week versus daily washing and topical application of an ointment effective against Gram-positive organisms (such as bacitracin) is generally safe and effective. Third-degree burns should be treated with daily dressing changes with either a silver containing cream such as silver sulfadiazine or a silver dressing. Avoid the use of tape or tightly wrapped dressings, as they can compromise blood flow to the burned extremity.

Sedation for Initial Wound Management

Moderate sedation is often needed for cleaning and dressing burn wounds in children shortly after injury. Children receiving sedation should be monitored using pulse oximetry and continuous electrocardiogram monitors. For minor burns in the office setting, oral midazolam (0.5 mg/kg) and oral analgesic agents (acetaminophen, hydrocodone/acetaminophen) may suffice. However, for larger burns intravenous agents such as ketamine (1 mg/kg intravenously) with midazolam or dexmedetomidine may be needed. If possible, engage the services of a professional trained in pediatric sedation to assist in initial burn dressing changes. Children should be followed at least weekly until either healed or scheduled for surgical intervention. In general, if a burn wound is not almost completely healed within 2 weeks, excision and grafting should be performed to minimize scarring and maximize function. ^{16 17}

Child Abuse

Each year > 600,000 children sustain injury due to child abuse or neglect, and the majority of the offenders are the parents. ¹⁸ Burn injuries account for approximately 10% of all child abuse cases, and approximately 10% of hospital admissions of children to burn units are due to abuse. ^{19 20} In 2021, 1,820 children died from abuse or neglect. ²¹ Identification of children who sustain abuse is important, as 50% sustain recurrent abuse and 30% of these children will die. ²² The most common groups affected are male children 2 to 4 years of age from low socioeconomic households with two or more children. ²³ Children at highest risk are those of nonwhite race, young parents lacking a high school education, lower income households, alcohol or substance abuse history in the household, public insurance or lack of insurance, and previous Children's Protective Services report. ^{24 25} Classic physical findings associated with burns of abuse include symmetrical extremity, perineal, and buttock burns. Other red flags for child abuse include delays in seeking care, changing stories on how the injury occurred, a mismatch between the burn appearance and the described accident, blaming the sibling or another child for the injury, and a glove-like burn distribution. ²⁶ A common scenario is a child in the toilet training years who soils the diaper and is burned in the bathtub when placed in hot water to clean the perineum. Lines can be seen on the buttocks, with sparing of the buttock cheek where the skin is in contact with the cool porcelain tub (donut hole sign). Conversely, a V-shaped wound on the chest is a common presentation for an accidental hot liquid spill. If there is doubt as to the congruence between the history provided and the injury, the child should be sent to a pediatric burn center experienced in child abuse cases.

Pediatric Burn Referral Guidelines

The American Burn Association updated the Guidelines for Patient Referral in 2022. ²⁷ The referral criteria are listed in Table 2 . One major difference in the revised guidelines is the addition of a category for immediate transfer versus burn center consultation. Generally, children less than 14 years of age or 30 kg should be referred to a burn center to address their unique needs, such as pain control, dressing changes, family support, rehabilitation, and nonaccidental trauma. Patient wounds should be washed, and a clean dressing applied prior to transportation. Application of topical creams should be avoided unless advised by the burn center. For small burns that will be seen in an outpatient clinic in several days, generally a nonadherent dressing, such as Xeroform or Adaptic, with bacitracin can be applied to the wound and secured with a loose gauze wrap, ace bandage, or netting.

Table 2. Burn center referral criteria ²⁷ .

	Immediate consultation for transfer	Consultation
Thermal burn	Full-thickness burn	Partial thickness < 10%
	Partial thickness burn ≥ 10% TBSA	Potential deep burns
	Deep partial or full-thickness burn of face, hands, genitalia, feet perineum, joints
	Burns with other comorbidities
	Concomitant trauma injuries
	Poorly controlled pain
Inhalation injury	All patients with suspected inhalation injury	Flash face burn injury
Pediatrics	All children with burn injury may benefit from burn center referral for pain, dressing change need, rehabilitation, caregiver issues, nonaccidental trauma
Chemical injury	All chemical injuries
Electrical injury	All high voltage (> 1000 V)	Low voltage (< 1000 V)
	Lightening injuries

Abbreviation: TBSA, total body surface area.

Conclusion

The care of children with burn injury follows the same basic principles as for adults, with special consideration for a child's specific needs. Recognition of the fundamental differences between adult and pediatric physiology facilitates optimal care and early identification of children who need advanced medical care. Even a small burn in a child can have lifelong implications. Appropriate initial management sets the stage for successful treatment and optimal outcomes. Finally, children with significant burns should be referred to a verified pediatric burn center to assure that they receive optimal initial care and long-term follow-up.